Daily blood loss transition after total knee arthroplasty with topical administration of tranexamic acid: Paradoxical blood loss after action of tranexamic acid

Abstract

Purpose: The purpose of this study was to compare the daily blood loss transition between groups with and without topical administration of tranexamic acid (TXA) after cruciate retaining (CR) and posterior stabilized (PS) total knee arthroplasty (TKA). Methods: A total of 220 patients undergoing unilateral TKA were enrolled in CR and PS TKAs, which were divided into groups that received topical administration of TXA (TXA group) or without TXA (non-TXA group). Each group in both types of TKA included 55 patients. The daily transition of blood loss was compared between the TXA and the non-TXA groups in CR and PS TKAs. The blood loss was calculated through Nadler formula using the patient's blood volume and hemoglobin reduction rate. Results: Total blood loss was significantly lower in the TXA group in both CR and PS TKAs (p < 0.001, respectively). The blood loss was lower for 0-24 h and 24-48 h after TKA. However, from 48 h to 72 h, it was greater in the TXA group (253.1 vs. 34.6 mL; p < 0.001) in CR TKAs. These tendencies were similar in PS TKAs after 48 h (186.2 vs. 134.9 mL, p ¼ 0.223). Conclusions: Topical administration of TXA for reduction of blood loss seemed to be effective up to 48 h after both CR and PS TKAs. The blood loss after 48 h tended to be even greater in the TXA group. Future studies will be required to identify the pharmacokinetic evidence for this clinical finding. Level of evidence: Level II.

Letter to the Editor

“…The present study by Song et al 1 would undoubtedly fuel more high-quality randomized trials with large sample size to unravel the pharmacokinetic complexities of TXA and its clinical significance.…”

“…These concerns were buttressed by the facts that there was no incidence of complications like wound discharge, discharge from drain removal site, bleeding, or hematoma. 1 Indeed, it remains to be seen how this paradoxical blood loss affects early functional recovery and rehabilitation after TKAs—evaluation of which with subjective knee function score or objective clinical examination would have added more credibility to the present research. Therefore, the pertinent questions naturally arise: Do surgeons need to be circumspect until more evidences are available at our disposal?…”

“…Second, it was established in this study that blood conservation efficacy of topical TXA abated 48 h after TKAs; nevertheless, it will be intriguing to see whether it bears any clinical significance, since transfusion requirements did not show any statistical difference between the groups. 1 Likewise, drainage volume on postoperative day 1 (PO1) (after 24 h of operation) was greater in TXA group; albeit it achieved statistical significance, however, I am afraid the differences seem small and might not be clinically relevant. These concerns were buttressed by the facts that there was no incidence of complications like wound discharge, discharge from drain removal site, bleeding, or hematoma.…”

“…I have read the recent article by Song et al 1 with great enthusiasm, which dwells with a clinically relevant subject that has been churning the scientific discourse for last few years. I extend my heartfelt appreciation to the authors for their research which sought to evaluate blood loss transition after total knee arthroplasty (TKA) with topical administration of tranexamic acid (TXA); they have found that topical TXA was effective in reducing blood loss and hemoglobin drop up to 48 h after TKAs, and paradoxical blood loss tended to occur in TXA group 48 h after operation.…”

“…Song et al in this study have speculated that paradoxical blood loss 48 h after TKAs could be explained by delayed fibrinolysis. 1 Against this backdrop, I believe, what could have made the denouement of their study more edifying is the postoperative analysis of fibrinolytic parameters, such as fibrin degradation product, and D-dimer level.…”