Multimodal blood loss prevention approach including intra‐articular tranexamic acid in primary total knee arthroplasty for patients with severe haemophilia A

Abstract

Total knee arthroplasty (TKA) is associated with blood loss, requiring blood transfusion in 44% of patients on average (range of 9-84%) [1]. Blood transfusion remains a standard treatment in case of postoperative anaemia after TKA, and in many institutions two packed red blood cell units are routinely prepared preoperatively for TKAs. However, the risks of blood transfusions are well established [2]. Many authors have reported the efficacy and safety of intravenous [3-7] and intra-articular [8,9] tranexamic acid (TXA) in preventing blood loss during TKA.The use of a multimodal blood loss prevention approach (MBLPA) that includes intra-articular TXA (MBLPA-TXA) has been shown to diminish the transfusion rate in TKA for persons without haemophilia [7][8][9]. However, the transfusion rates, haematological parameters that assess the prevention of blood loss, factor consumption and cost of surgery have not yet been defined in persons with haemophilia (PWH) when using the MBLPA-TXA. Our aim is to demonstrate that the MBLPA-TXA decreases the rate of postoperative blood transfusions by preventing blood loss, diminishing factor consumption in PWH.We conducted a retrospective case-control comparative study, including 10 PWH [severe haemophilia Aless than 1% factor VIII (FVIII) basal activity] with unilateral primary TKA at our institution. We included all PWH undergoing primary TKA in our institution since 1 January 2013 to 31 December 2013 (we currently perform around 10 TKAs per year in our centre). Patients were not selected to show a positive effect. The same surgeons did all the procedures and all patients were nursed in the same hospital on the same ward. Sex and preoperative haemoglobin (Hb) and haematocrit (Hct) were the same in both groups. The surgical technique was identical in both groups.

Abrogating fibrinolysis does not improve bleeding or rFVIIa/rFVIII treatment in a non‐mucosal venous injury model in haemophilic rodents

“…Although antifibrinolytic drugs have been proven to be effective as adjunctive HA therapy for mucosal bleeds , in non‐mucosal tissues they are mainly used empirically. Only limited evidence supports the use of antifibrinolytic drugs in cases of non‐mucosal bleeding and in surgical operations . Moreover, no study has definitively shown the usefulness of systemic TXA therapy in patients with HA.…”

Opioid-Free Total Knee Arthroplasty? Local Infiltration Analgesia Plus Multimodal Blood-Loss Prevention Make it Possible

“…The other protocol (and mostly used at this moment) includes intra-articular TXA administration (2 g in 20 cc of saline) after wound closure, without intravenous doses. Good results have been reported with such protocols in primary TKA, revision TKA, and hemophilic patients [17,[24][25][26].…”

The role of orthopaedic surgery in haemophilia: current rationale, indications and results

“…The MBLPA-TXA group included the following: (a) tourniquet with 100 mmHg above systolic pressure, released after skin closure; (b) surgical blood-saving protocol, including: femoral canal obturation with bone graft and intra-articular infiltration of posterior capsule, medial and lateral capsule, and ligaments, before closure, of 80 cc saline with adrenalin 300 mcg, morphic chloride 10 mg, tobramycin 100 mg, betamethasone sodium phosphate 6 mg, betamethasone acetate 6 mg, and ropivacaine 200 mg; (c) an intra-articular injection of a combination of TXA (25 mL, 2500 mg) and sodium chloride (10 mL, 18 mg). 32…”

“…In the non-MBLPA-TXA group, the standard procedure was used, without any particular blood-saving technique (tourniquet with 350 mmHg, released before skin closure for electrocoagulation of bleeding; no limits or treatment to preoperative haemoglobin; no femoral canal obturation, 24–48 hour vacuum drain, opened with skin closure, no intra-articular infiltration; and no TXA administration). 32…”