Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty

Nielsen, Christian Skovgaard; Jans, Øivind; Ørsnes, Thue; Foss, Nicolai Bang; Troelsen, Anders; Husted, Henrik

doi:10.2106/jbjs.15.00810

Cited by 108 publications

(111 citation statements)

References 34 publications

(39 reference statements)

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“…Seven studies give a detailed description of the random sequence generation, [18,20–22,24,26,27,30] and 5 trials perform the allocation concealment. [18,19,22,26,30] TXA is an anti-fibrinolytic agent, and the efficacy of TXA was tested by the total blood loss and patients’ need for transfusion. The antifibrinolytic agents have the potential to increase the occurrence of DVT; thus, the safety of TXA was measured by the occurrence of DVT.…”

Section: Resultsmentioning

confidence: 99%

“…A total of 7 trials [20–22,24,26,27,30] with 1110 patients perform the total blood loss after TKA, and 7 studies [20–22,24,26,27,30] compared the combined topical TXA with intravenous TXA with control, 3 studies [19,21,28] compared the combined topical TXA with intravenous TXA with intravenous TXA, and 3 studies [18,21,24] compared the combined TXA with the topical administration TXA. The pooled meta-analysis indicated that the combined topical TXA with intravenous TXA can reduce the total blood loss compared with placebo with a mean of 458.66 mL and the difference is statistically significant (MD = −458.66, 95% CI: −655.40 to 261.91, P < 0.001, Fig.…”

Section: Resultsmentioning

confidence: 99%

“…A total of 9 [18–22,24,26–28] studies perform the data of the need for transfusion after TKA and pooled results indicated that combined topical with intravenous TXA can decrease the need for transfusion (RR = 0.34, 95% CI: 0.23–0.50, P < 0.001, Fig. 7).…”

Section: Resultsmentioning

confidence: 99%

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Is combined topical with intravenous tranexamic acid superior than topical, intravenous tranexamic acid alone and control groups for blood loss controlling after total knee arthroplasty

Lin

et al. 2016

Medicine

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Background:The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the efficacy and safety of combined topical with intravenous tranexamic acid (TXA) versus topical, intravenous TXA alone or control for reducing blood loss after a total knee arthroplasty (TKA).Methods:In May 2016, a systematic computer-based search was conducted in the PubMed, Embase, Cochrane Library, Web of Science, and Chinese Wanfang database. This systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement criteria. Only patients prepared for primary TKA that administration combined topical with intravenous TXA with topical TXA, intravenous (IV) TXA, or control group for reducing blood loss were included. Eligible criteria were published RCTs about combined topical with intravenous TXA with topical alone or intravenous alone. The primary endpoint was the total blood loss and need for transfusion. The complications of deep venous thrombosis (DVT) were also compiled to assess the safety of combined topical TXA with intravenous TXA. Relative risks (RRs) with 95% CIs were estimated for dichotomous outcomes, and mean differences (MDs) with 95% CIs for continuous outcomes. The Cochrane risk of bias tool was used to appraise a risk of bias. Stata 12.0 software was used for meta-analysis.Results:Fifteen studies involving 1495 patients met the inclusion criteria. The pooled meta-analysis indicated that combined topical TXA with intravenous TXA can reduce the total blood loss compared with placebo with a mean of 458.66 mL and the difference is statistically significant (MD = −458.66, 95% CI: −655.40 to 261.91, P < 0.001). Compared with intravenous TXA, combined administrated TXA can decrease the total blood loss, and the difference is statistically significant (MD = −554.03, 95% CI: −1066.21 to −41.85, P = 0.034). Compared with the topical administration TXA, the pooled meta-analysis indicated that combined TXA can decrease the amount of total blood loss with mean 107.65 mL with statistically significant(MD = −107.65, 95% CI: −525.55 to −239.9141.85, P = 0.001). The pooled results indicated that combined topical with intravenous TXA can decrease the need for transfusion (RR = 0.34, 95% CI: 0.23–0.50, P < 0.001). There is no significant difference between combined topical with intravenous TXA with topical or intravenous TXA (P > 0.05) in terms of need for transfusion and the occurrence of DVT.Conclusion:Compared with topical, intravenous TXA alone or control group, combined topical with TXA, can decrease the total blood loss and subsequent need for transfusion without increasing the occurrence of DVT. The dose and timing to administration TXA is different, and more randomized controlled trials are warranted to clarify the optimal dosing and time to administration TXA.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Is combined topical with intravenous tranexamic acid superior than topical, intravenous tranexamic acid alone and control groups for blood loss controlling after total knee arthroplasty

Lin

et al. 2016

Medicine

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“…It was shown that this method (combined TXA) can effectively reduce the amount of bleeding after TKA. Nevertheless, these studies reported inconsistent results of comparing combined TXA with IV or IA TXA alone on TKA [15–17]. Therefore, this meta-analysis was designed to compare the effectiveness and safety of combined TXA with IV TXA or IA TXA for patients undergoing primary TKA through evaluating the total blood loss, blood volume of drainage, transfusion rate, and thromboembolic complications.…”

Section: Introductionmentioning

confidence: 99%

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

Liu

et al. 2017

J Orthop Surg Res

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BackgroundTranexamic acid (TXA) has been proven to be effective in reducing blood loss and transfusion rate after total knee arthroplasty (TKA) without increasing the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Recently, an increasing number of studies have been interested in applying combined intravenous (IV) with intraarticular (IA) tranexamic acid in total knee arthroplasty. The purpose of this meta-analysis was to compare the blood loss and complications of combined TXA with IV TXA or IA TXA on TKA.MethodsSystematic search of literatures were conducted to identify related articles that were published in PubMed, MEDLINE, Embase, the Cochrane Library, SpringerLink, ClinicalTrials.gov, and Ovid from their inception to September 2016. All studies that compare blood loss and complications of combined TXA and IV TXA or IA TXA on TKA were included. Main outcomes were collected and analyzed by the Review Manager 5.3.ResultsFive studies were included in the present meta-analysis. There was significant difference in total blood loss and blood volume of drainage when compared combined TXA group with IV TXA group or IA TXA group (P < 0.05). There was no difference in transfusion rate and thromboembolic complications when comparing combined TXA with IV TXA or IA TXA alone (P > 0.05).ConclusionsCompared with administration of IA TXA or IV TXA alone on TKA, combined use of TXA has advantages in reducing total blood loss and blood volume of drainage without increasing the incidence of thromboembolic complications. We recommend combined TXA as the preferred option for patients undergoing TKA.

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“…Combined intra-articular and intravenous delivery has been shown to result in a greater reduction in blood loss than intravenous delivery alone for primary TKA,55 or intra-articular delivery alone for revision TKA 56. Intra-articular delivery alone may be as efficacious as intravenous57 or combined intra-articular and intravenous delivery58 for primary TKA; however, the use of different tranexamic doses between studies limits the interpretation.…”

Section: Intraoperativementioning

confidence: 99%

Blood management in total knee arthroplasty: state-of-the-art review

et al. 2018

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Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.

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Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty

Abstract: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cited by 108 publications

References 34 publications

Is combined topical with intravenous tranexamic acid superior than topical, intravenous tranexamic acid alone and control groups for blood loss controlling after total knee arthroplasty

Is combined topical with intravenous tranexamic acid superior than topical, intravenous tranexamic acid alone and control groups for blood loss controlling after total knee arthroplasty

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

Blood management in total knee arthroplasty: state-of-the-art review

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