Multi-route applications of tranexamic acid to reduce blood loss after total knee arthroplasty: a randomized controlled trial

Abstract

Background: Perioperative bleeding during total knee arthroplasty (TKA) is an ongoing problem for surgeons. Intravenous or topical application of tranexamic acid (TXA) can effectively stop bleeding, but there is still no uniform standard for the best method of administration and dose. Methods: From October 2016 to September 2018, 218 patients with unilateral primary knee osteoarthritis requiring knee replacement were enrolled and randomly divided into four groups. Group 1 (n = 55) received intra-articular injection (IAI) of TXA and peri-articular injection (PAI) of placebo, group 2 (n = 55) received IAI of placebo and PAI of TXA, group 3 (n = 51) received IAI of TXA and PAI of TXA, and group 4 (n = 57) received double placebo (IAI of placebo and PAI of placebo). The demographic characteristics, surgical indices, hematological indices, wound healing history, and thromboembolic events were investigated. Results: Eight patients were lost to follow-up and 210 patients were included in the analysis. The median TBLs in patients who received IAI of TXA and PAI of placebo and those who received IAI of placebo and PAI of TXA were 470.81 ml and 481.54 ml, respectively. These TBL levels were significantly higher compared to those in patients who received IAI of TXA and PAI of TXA (359.18 ml, P ≤ .001), but significantly lower compared to those in patients who received the double placebo (522.71 ml, P ≤ .001). Compared to other groups, more patients in the double placebo group needed a blood transfusion ( P = .013). In the short-term, the double placebo group had higher VAS pain scores and less ROM after surgery ( P = .011 and P = .001, respectively). In the long-term (6-month follow-up), there were no significant differences in ROM, VAS, DVT, PE, or wound-related complications. Conclusion: The combined use of IAI and PAI of TXA can significantly reduce the TBL and the need for blood transfusion without delaying wound healing or increasing the risk of DVT and PE. In the short-term after surgery, this combined method reduces the pain VAS scores and improves the ROM; however, there are no long-term effects on VAS and ROM.

Combined and intravenous administration of TXA reduces blood loss more than topical administration in primary total knee arthroplasty: A randomized clinical trial

“…According to recent meta-analyses of RCTs, intravenous administration is preferred for primary TKA due to its rapid onset of action and longer stability of therapeutic TXA concentration in the bleeding site 2,11 . Compared to topical administration, the effect of intravenous administration in the bleeding site is up to 5 h longer 2 .…”

“…Most studies have been performed with systemic and topical administration of TXA (ref. 1,2 ). However, there are still concerns about the potential risk of thromboembolic disease in the case of intravenous administration in higher doses 3,4 .…”

“…We found no significant effect on systemic markers of fibrinolysis in either regimen. Although many excellent studies have focused on search for the optimal protocol for use of TXA in TKA, differences in views on the optimal regimen of TXA administration have only increased 1,2,8 . Even large-scale randomized studies and meta-analyses do not provide consistent conclusions on the proper administration of TXA in terms of dose or number of doses 11 .…”

The Comparative Efficacies of Intravenous Administration And Intra-Articular Injection of Tranexamic Acid During Anterior Cruciate Ligament Reconstruction For Reducing Postoperative Hemarthrosis: A Prospective Randomized Study

“…Tranexamic acid (TXA), as an anti brinolytic agent derived from lysine, binds to lysine receptor sites on plasminogen and prevents the formation of plasmin, thus inhibiting the breakdown of brin clots and reducing active bleeding [6,7]. TXA has a great role in reducing postoperative blood loss, the need for transfusion and hospital-related costs after total knee arthroplasty (TKA) without increasing the rate of deep venous thrombosis (DVT) [6,8]. There are two major administration routes in the use of TXA: intravenous (IV) administration and intra-articular (IA) injection.…”

The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction for reducing postoperative hemarthrosis

“…Tranexamic acid (TXA), as an anti brinolytic agent derived from lysine, binds to lysine receptor sites on plasminogen and prevents the formation of plasmin, thus inhibiting the breakdown of brin clots and reducing active bleeding [6,7]. TXA has a great role in reducing postoperative blood loss, the need for transfusion and hospital-related costs after total knee arthroplasty (TKA) without increasing the rate of deep venous thrombosis (DVT) [6,8]. There are two major administration routes in the use of TXA:…”