Do We Concern Ourselves with Blood Loss and Blood Transfusions of the Peri-articular Injection of Tranexamic Acid after Unilateral Total Knee Arthroplasty?

Year 2022, , 184 - 193, 31.08.2022

Aziz Çataltepe , Kadir Öznam

https://doi.org/10.47493/abantmedj.1016189

Abstract

Objective: The means of peri-articular (PA) administration of tranexamic acid (TXA) is not examined sufficiently in unilateral total knee arthroplasty (TKA). The primary purpose of this study was to evaluate postoperative blood loss and transfusions rates after the administration of PA injection of TXA in TKA. In addition, PA TXA may decrease pain owing to reduced hemarthrosis after TKA.

Materials and Methods: In this retrospective study, 113 patients who underwent a primary unilateral TKA with or without a PA injection of TXA were included. A total of 1500 mg/50 ml TXA was injected into the extra-articular soft tissue around the medial, lateral capsules and muscular soft tissue around the quadriceps tendon immediately after cementation the prothesis, but before capsular closure and 15 minutes before the deflation of the tourniquet. A total of 56 patients in the control group did not receive TXA. The surgical procedure was standardized in all of the patients.

Results: There was a statistically significant reduction in hidden blood loss, estimated blood loss, and receiving a postoperative allogeneic blood transfusion in the TXA group compared with the control group (p=0.0001). We found a significant correlation between blood transfusion and the length of hospital stay (p=0.0001). No significant difference was found regarding pain VAS score after postoperative 1st day and postoperative 3rd day (p=0.597 and p=0.183, respectively). 1500 mg/50 ml (30 mg/ml) TXA was a relatively optimal dose to minimize the cytotoxic effects on the soft tissue around the knee compared with 50 mg/ml. No patients encountered any thromboembolic and wound complications.

Conclusion: The PA administration of TXA may offer a significant reduction in postoperative blood loss and transfusions rates as well as the length of hospital stay without increasing the risk of thromboembolic complications and cytotoxic effects on cartilage and peri-articular soft tissue. However, we did not observe a significant reduction in postoperative pain VAS score.

Keywords

Total Knee Arthroplasty, Tranexamic Acid, Peri-Articular Injection, Blood Loss

Tek Taraflı Total Diz Artroplastisi Sonrası Traneksamik Asit Peri-artiküler Enjeksiyonunun Kan Kaybı ve Kan Transfüzyonları ile İlgili Endişemiz Var mı?

Abstract

Amaç: Tek taraflı total diz artroplastisinde (TDA) traneksamik asidin (TXA) peri-artiküler (PA) uygulama şekli yeterince incelenmemektedir. Bu çalışmanın birincil amacı, TDA'da TXA'nın PA enjeksiyonunun uygulanmasından sonra postoperatif kan kaybı ve transfüzyon oranlarını değerlendirmekti. Ek olarak, PA TXA, TDA sonrası hemartrozun azalması nedeniyle ağrıyı azaltabilir.

Gereç ve Yöntemler: Bu retrospektif çalışmaya TXA PA enjeksiyonu olan veya olmayan primer tek taraflı TDA uygulanan 113 hasta dahil edildi. Protezin simante edilmesinden sonra, ancak kapsül kapanmadan ve turnike indirilmeden 15 dakika önce, medial, lateral kapsüller ve kuadriseps tendonu çevresindeki kas yumuşak doku çevresindeki eklem dışı yumuşak dokuya toplam 1500 mg/50 ml TXA enjekte edildi. Kontrol grubundaki toplam 56 hasta TXA almadı. Tüm hastalarda cerrahi prosedür standardize edildi.

Bulgular: Kontrol grubuna kıyasla TXA grubunda gizli kan kaybında, tahmini kan kaybında ve postoperatif allojenik kan transfüzyonu almada istatistiksel olarak anlamlı bir azalma vardı (p=0,0001). Kan transfüzyonu ile hastanede kalış süresi arasında anlamlı bir ilişki bulduk (p=0,0001). Postoperatif 1. gün ve postoperatif 3. günden sonra ağrı VAS skoru açısından anlamlı bir fark bulunmadı (p=0,597 ve p=0,183, sırasıyla). 1500 mg/50 ml (30 mg/ml) TXA, 50 mg/ml. ile karşılaştırıldığında diz çevresindeki yumuşak doku üzerindeki sitotoksik etkileri en aza indirmek için nispeten optimal bir dozdu. Hiçbir hastada herhangi bir tromboembolik ve yara komplikasyonu görülmedi.

Sonuç: TXA'nın PA uygulaması, tromboembolik komplikasyon ve kıkırdak ve periartiküler yumuşak doku üzerinde sitotoksik etki riskini artırmadan, postoperatif kan kaybı ve transfüzyon oranlarında ve hastanede kalış süresinde önemli bir azalma sağlayabilir. Ancak postoperatif ağrı VAS skorunda anlamlı bir azalma gözlemlemedik.

Keywords

Total Diz Artroplastisi, Traneksamik Asit, Periartiküler Enjeksiyon, Kan Kaybı

References

• 1. Huang Z, Ma J, Shen B, Pei F. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty. 2014 Dec;29(12):2342-6.
• 2. Goodnough LT (2005) Risks of blood transfusion. Anesthesiol Clin North Am 23(2):241–252.
• 3. Lu Q, Peng H, Zhou GJ, Yin D. Perioperative Blood Management Strategies for Total Knee Arthroplasty. Orthop Surg. 2018 Feb;10(1):8-16.
• 4. White CC 4th, Eichinger JK, Friedman RJ. Minimizing Blood Loss and Transfusions in Total Knee Arthroplasty. J Knee Surg. 2018 Aug;31(7):594-599.
• 5. 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 May;90(5):596-9.
• 6. Murphy WG, Davies MJ, Eduardo A. The haemostatic response to surgery and trauma. Br J Anaesth. 1993 Feb;70(2):205-13.
• 7. Levy JH. Antifibrinolytic therapy: new data and new concepts. Lancet. 2010 Jul 3;376(9734):3-4.
• 8. 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 Nov;35(11):1639-45.
• 9. Xu S, Chen JY, Zheng Q, Lo NN, Chia SL, Tay KJD, Pang HN, Shi L, Chan ESY, Yeo SJ. The safest and most efficacious route of tranexamic acid administration in total joint arthroplasty: A systematic review and network meta-analysis. Thromb Res. 2019 Apr;176:61-66.
• 10. Peng H, Wang L, Weng X, Zhai J, Lin J, Jin J, Qian W, Gao N. Effect of tranexamic acid on symptomatic venous thromboembolism in patients undergoing primary total knee arthroplasty. Arch Med Sci. 2020 Jan 19;16(3):603-612.
• 11. Mao Z, Yue B, Wang Y, Yan M, Dai K. A comparative, retrospective study of peri-articular and intra-articular injection of tranexamic acid for the management of postoperative blood loss after total knee arthroplasty. BMC Musculoskelet Disord. 2016 Oct 19;17(1):438.
• 12. Patel JN, Spanyer JM, Smith LS, Huang J, Yakkanti MR, Malkani AL. Comparison of intravenous versus topical tranexamic acid in total knee arthroplasty: a prospective randomized study. J Arthroplasty. 2014 Aug;29(8):1528-31.
• 13. Meshram P, Palanisamy JV, Seo JY, Lee JG, Kim TK. Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial. Clin Orthop Relat Res. 2020 Jan;478(1):45-54.
• 14. Konig G, Hamlin BR, Waters JH. Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty. J Arthroplasty. 2013 Oct;28(9):1473-6.
• 15. Tuttle JR, Feltman PR, Ritterman SA, Ehrlich MG. Effects of Tranexamic Acid Cytotoxicity on In Vitro Chondrocytes. Am J Orthop (Belle Mead NJ). 2015 Dec;44(12):E497-502.
• 16. Benoni G, Lethagen S, Fredin H. The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res. 1997 Feb 1;85(3):195-206.
• 17. Pinsornsak P, Rojanavijitkul S, Chumchuen S. Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial. BMC Musculoskelet Disord. 2016 Jul 26;17:313.
• 18. Yozawa S, Ogawa H, Matsumoto K, Akiyama H. Periarticular Injection of Tranexamic Acid Reduces Blood Loss and the Necessity for Allogeneic Transfusion After Total Knee Arthroplasty Using Autologous Transfusion: A Retrospective Observational Study. J Arthroplasty. 2018 Jan;33(1):86-89.
• 19. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery. 1962 Feb;51(2):224-32.
• 20. Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology. 1983 Mar;58(3):277-80.
• 21. Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br. 2004 May;86(4):561-5.
• 22. Goderecci R, Giusti I, Necozione S, Cinque B, D'Ascenzo S, Dolo V, Calvisi V. Short exposure to tranexamic acid does not affect, in vitro, the viability of human chondrocytes. Eur J Med Res. 2019 Feb 22;24(1):15.
• 23. Hirose H, Ogawa H, Matsumoto K, Akiyama H. Periarticular injection of tranexamic acid promotes early recovery of the range of knee motion after total knee arthroplasty. J Orthop Surg (Hong Kong). 2019 Sep-Dec;27(3):2309499019864693.
• 24. Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br. 2001 Jul;83(5):702-5.
• 25. McCormack PL. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs. 2012 Mar 26;72(5):585-617.
• 26. Wong J, Abrishami A, El Beheiry H, Mahomed NN, Roderick Davey J, Gandhi R, Syed KA, Muhammad Ovais Hasan S, De Silva Y, Chung F. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am. 2010 Nov 3;92(15):2503-13.
• 27. Reale D, Andriolo L, Gursoy S, Bozkurt M, Filardo G, Zaffagnini S. Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials. Biomed Res Int. 2021 Jan 16;2021:6961540.
• 28. Astedt B, Liedholm P, Wingerup L. The effect of tranexamic acid on the fibrinolytic activity of vein walls. Ann Chir Gynaecol. 1978;67(6):203-5.
• 29. McLean M, McCall K, Smith IDM, Blyth M, Kitson SM, Crowe LAN, Leach WJ, Rooney BP, Spencer SJ, Mullen M, Campton JL, McInnes IB, Akbar M, Millar NL. Tranexamic acid toxicity in human periarticular tissues. Bone Joint Res. 2019 Feb 2;8(1):11-18.
• 30. Çıraklı A, Gürgör PN, Uzun E, Erdem H, Çankaya S, Baş O. Local application of tranexamic acid affects tendon healing negatively in the late period. Eklem Hastalik Cerrahisi. 2018 Apr;29(1):20-6.