An In Vivo Study of Low-Dose Intra-Articular Tranexamic Acid Application with Prolonged Clamping Drain Method in Total Knee Replacement: Clinical Efficacy and Safety

Abstract

Background. Recently, combined intra-articular tranexamic acid (IA-TXA) injection with clamping drain method showed efficacy for blood loss and transfusion reduction in total knee replacement (TKR). However, until now, none of previous studies revealed the effect of this technique on pharmacokinetics, coagulation, and fibrinolysis. Materials and Methods. An experimental study was conducted, during 2011-2012, in 30 patients undergoing unilateral TKR. Patients received IA-TXA application and then were allocated into six groups regarding clamping drain duration (2-, 4-, 6-, 8-, 10-, and 12-hours). Blood and drainage fluid were collected to measure tranexamic acid (TXA) level and related coagulation and fibrinolytic markers. Postoperative complication was followed for one year. Results. There was no significant difference of serum TXA level at 2 hour and 24 hour among groups (p < 0.05). Serum TXA level at time of clamp release was significantly different among groups with the highest level at 2 hour (p < 0.0001). There was no significant difference of TXA level in drainage fluid, postoperative blood loss, blood transfusion, and postoperative complications (p < 0.05). Conclusions. Low-dose IA-TXA application in TKR with prolonged clamping drain method is a safe and effective blood conservative technique with only minimal systemic absorption and without significant increase in systemic absorption over time.

Are closed suction drains necessary for primary total knee arthroplasty?

“…Some authors proposed that due to the lack of “self-tamponade” effect, the use of drains might be associated with an elevated amount of total blood loss; meanwhile, blood perfusion around the wound reactively increases within hours after operation and therefore the drain tubes were advised to be clamped for about 4 to 6 hours. [ 31 , 32 ] Although we did not observe a significant difference in calculating blood loss or hemoglobin drop between the drainage group and the nondrainage group, elevated rate of postoperative homologous blood transfusion did correlate with the insertion of closed suction drains. The plausible reason is the heterogeneous and sometimes subjective criteria for transfusion.…”

A prospective, randomized, comparative study of intravenous alone and combined intravenous and intraarticular administration of tranexamic acid in primary total knee replacement

“…There is, however, evidence that the combined use of TXA and clamped drains is more effective in reducing blood loss compared to TXA or drain to clamping alone [41] . The choice of clamping the drainage for 3 hours was based on the evidence that this timing optimizes the action of IA TXA [42] and follows the evidence that the half-life of IA TXA has been shown to be 3 hours [43] , avoiding, at the same time, the risk of clots formation that could obstruct the drain, in case of prolonged clamping (it is the authors' experience that this happen when drainage is kept clamped for more than 3 hours). In addition, we insufflated the tourniquet for a short time, because there is evidence that the combined use of tourniquet application and TXA administration provides advantages in terms of operative time and bleeding control [44] , [45] .…”

Quantitative efficacy of topical administration of tranexamic acid on postoperative bleeding in total knee arthroplasty

“…Recent meta‐analyses have shown that various topical dosing regimens were effective. They reported a wide range of 0.25–3 g in a single dose and of 5 min to 12 h for the drug contact time . However, the optimal regimen remains undetermined.…”

“…Recent meta-analyses have shown that various topical dosing regimens were effective. They reported a wide range of 0.25-3 g in a single dose and of 5 min to 12 h for the drug contact time [12][13][14]. However, the optimal regimen The conventional meta-analysis is limited by pooling of data at different time points and large intertrial variability (shown in Figure 2A) in the drainage volume of the placebo group across studies.…”