A retrospective investigation of the effect of tranexamic acid application and tourniquet duration on postoperative bleeding amount in patients undergoing total knee arthroplasty

Abstract

Objectives: It is aimed to investigate the effect of tourniquet and tranexamic acid (TXA) on the amount of perioperative bleeding in patients undergoing total knee arthroplasty.

Methods: One hundred and ninety-three patients included in the study. The patients included in the study were divided into 4 groups. Group 1 (n = 78) was determined as the patient group with long-term tourniquet application, but without additional application and was accepted as the control group. Group 2 (n = 40) was the long-term tourniquet and intravenous (IV) TXA applied group, Group 3 (n = 40) was the long-term tourniquet and intra-articular TXA applied group, and Group 4 (n = 35) was the short-term tourniquet (only in the cementing phase) and IV TXA applied group. The difference between groups according to use of a tourniquet during the operation, the method and dose of TXA, the amount of postoperative blood transfusion, the amount of drained blood, the length of hospital stay, and complications were investigated.

Results: The largest Hemoglobin (Hb) and Hematocrit (Hct) decreases were found in Group 1 (3.39 ± 0.92 g/dl and 10.8%, respectively). Also the highest drainage (median 350 ml), transfusion (16.7%), length of hospital stay (mean 4.51 ± 1.07 days) and estimated blood loss (median 1559.8 ml) were in Group 1 (p < 0.05). The lowest Hb decrease (mean 2.95 ± 0.68 g/dl) and lowest drainage (median 150 ml) was seen in group 3 and the lowest length of hospital stay (mean 3.89 ± 0.8 days) in group 4 (p < 0.05).

Conclusions: The use of TXA was shown to lead to a reduction in Hb and Hct, the amount of blood drained after surgery, and the length of hospital stay. The use of TXA may be a good option for bleeding control in patients undergoing total knee arthroplasty.

Keywords

• arthroplasty
• tranexamic acid
• tourniquets
• drains

References

1. 1. Lei Y, Xie J, Huang Q, Huang W, Pei F. Additional benefits of multiple-dose tranexamic acid to anti-fibrinolysis and anti-inflammation in total knee arthroplasty: a randomized controlled trial. Arch Orthop Trauma Surg 2020;140:1087-95.
2. 2. Huang Z, Xie X, Li L, Huang Q, Ma J, Shen B, et al. Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary total knee arthroplasty: a prospective, randomized controlled trial. J Bone Joint Surg Am 2017;99:2053-61.
3. 3. Huang ZY, Pei FX, Ma J, Yang J, Zhou ZK, Kang PD, et al. Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial. Arch Orthop Trauma Surg 2014;134:561-70.
4. 4. Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty?. Correct blood loss management should take hidden loss into account. Knee 2000;7:151-5.
5. 5. Rosencher N, Kerkkamp HE, Macheras G, Munuera LM, Menichella G, Barton DM, et al. Orthopedic surgery transfusion hemoglobin European overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion 2003;43:459-69.
6. 6. Ye W, Liu Y, Liu WF, Li XL, Fei Y, Gao X. 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. J Orthop Surg Res 2020;15:21.
7. 7. Taneja A, El-Bakoury A, Khong H, Railton P, Sharma R, Johnston KD, et al. Association between allogeneic blood transfusion and wound infection after total hip or knee arthroplasty: a retrospective case-control study. J Bone Jt Infect 2019;4:99-105.
8. 8. Sharqzad AS, Cavalheiro C, Zahar A, Lausmann C, Gehrke T, Kendoff D, et al. Blood loss and allogeneic transfusion for surgical treatment of periprosthetic joint infection: a comparison of one- vs. two-stage exchange total hip arthroplasty. Int Orthop 2019;43:2025-30.

9. 9. Sandri A, Mimor BF, Ditta A, Finocchio E, Danzi V, Piccoli P, et al. Perioperative intravenous tranexamic acid reduces blood transfusion in primary cementless total hip arthroplasty. Acta Biomed 2019;90(1-S):81-6.
10. 10. Wang K, Ni S, Li Z, Zhong Q, Li R, Li H, et al. The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 2017;25:2849-57.
11. 11. Ozkunt O, Sariyilmaz K, Gemalmaz HC, Dikici F. The effect of tourniquet usage on cement penetration in total knee arthroplasty: A prospective randomized study of 3 methods. Medicine (Baltimore) 2018;97:e9668.
12. 12. Dennis DA, Kittelson AJ, Yang CC, Miner TM, Kim RH, Stevens-Lapsley JE. Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res 2016;474:69-77.
13. 13. Zhou K, Ling T, Wang H, Zhou Z, Shen B, Yang J, et al. Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. J Orthop Surg Res 2017;12:172.
14. 14. Liu PL, Li DQ, Zhang YK, Lu QS, Ma L, Bao XZ, et al. Effects of unilateral tourniquet used in patients undergoing simultaneous bilateral total knee arthroplasty. Orthop Surg 2017;9:180-5.
15. 15. Fan Y, Jin J, Sun Z, Li W, Lin J, Weng X, et al. The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. Knee 2014;21:1263-8.
16. 16. Ejaz A, Laursen AC, Kappel A, Laursen MB, Jakobsen T, Rasmussen S, et al. Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop 2014;85:422-6.
17. 17. Stowers MDJ, Aoina J, Vane A, Poutawera V, Hill AG, Munro JT. Tranexamic acid in knee surgery study: a multicentered, randomized, controlled trial. J Arthroplasty 2017;32:3379-84.
18. 18. Fillingham YA, Kayupov E, Plummer DR, Moric M, Gerlinger TL, Della Valle CJ. The James A. Rand young investigator's award: a randomized controlled trial of oral and intravenous tranexamic acid in total knee arthroplasty: the same efficacy at lower cost? J Arthroplasty 2016;31(9 Suppl):26-30.
19. 19. Wu G, Mazzitelli BA, Quek AJ, Veldman MJ, Conroy PJ, Caradoc-Davies TT, et al. Tranexamic acid is an active site inhibitor of urokinase plasminogen activator. Blood Adv 2019;3:729-33.
20. 20. Morales Santias M, Mas Martinez J, Sanz-Reig J, Martinez Gimenez E, Verdu Roman C, Bustamante Suarez de Puga D. Topical tranexamic acid in cemented primary total knee arthroplasty without tourniquet: a prospective randomized study. Eur J Orthop Surg Traumatol 2020;30:1003-8.
21. 21. Meng Y, Li Z, Gong K, An X, Dong J, Tang P. Tranexamic acid reduces intraoperative occult blood loss and tourniquet time in obese knee osteoarthritis patients undergoing total knee arthroplasty: a prospective cohort study. Ther Clin Risk Manag 2018;14:675-83.
22. 22. Tzatzairis T, Drosos GI, Vogiatzaki T, Tilkeridis K, Ververidis A, Kazakos K. Multiple intravenous tranexamic acid doses in total knee arthroplasty without tourniquet: a randomized controlled study. Arch Orthop Trauma Surg 2019;139:859-68.
23. 23. van der Merwe JM, Mastel MS. Controversial topics in total knee arthroplasty: a five-year update (part 2). J AAOS: Glob Res Rev 2020;4:e19.00048.
24. 24. Brusalis CM, Bostrom MPG, Richardson SS. Has tranexamic acid in total knee arthroplasty made tourniquet use obsolete? HSS J 2018;14:338-40.
25. 25. Xie J, Hu Q, Huang Q, Ma J, Lei Y, Pei F. Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: an updated meta-analysis. Thromb Res 2017;153:28-36.
26. 26. Guo P, He Z, Wang Y, Gao F, Sun W, Guo W, et al. Efficacy and safety of oral tranexamic acid in total knee arthroplasty: a systematic review and meta-analysis. Medicine (Baltimore) 2018;97:e0587.
27. 27. Cao G, Xie J, Huang Z, Huang Q, Chen G, Lei Y, et al. Efficacy and safety of multiple boluses of oral versus intravenous tranexamic acid at reducing blood loss after primary total knee arthroplasty without a tourniquet: a prospective randomized clinical trial. Thromb Res 2018;171:68-73.
28. 28. Han X, Gong G, Han N, Liu M. Efficacy and safety of oral compared with intravenous tranexamic acid in reducing blood loss after primary total knee and hip arthroplasty: a meta-analysis. BMC Musculoskelet Disord 2018;19:430.
29. 29. Zhang YM, Yang B, Sun XD, Zhang Z. Combined intravenous and intra-articular tranexamic acid administration in total knee arthroplasty for preventing blood loss and hyperfibrinolysis: a randomized controlled trial. Medicine (Baltimore) 2019;98:e14458.
30. 30. Li Y, Lu M, Tian H, Li ZJ, Zhang K. [Effect of different tourniquet releasing strategy on blood loss in total knee arthroplasty]. Zhonghua Yi Xue Za Zhi 2017;97:3219-24. [Article in Chinese]