Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Musculoskeletal Disorders
Published in: BMC Musculoskeletal Disorders 1/2018

Open Access 01-12-2018 | Research article

Combined use of topical intraarticular tranexamic acid and rivaroxaban in total knee arthroplasty safely reduces blood loss, transfusion rates, and wound complications without increasing the risk of thrombosis

Authors: Yong Tae Kim, Min Wook Kang, Joon Kyu Lee, Young Min Lee, Joong Il Kim

Published in: BMC Musculoskeletal Disorders | Issue 1/2018

Login to get access

Abstract

Background

Blood loss and deep vein thrombosis (DVT) are important complications after total knee arthroplasty (TKA). Topical tranexamic acid (TXA) effectively reduces wound bleeding but may elevate the risk of DVT. In contrast, rivaroxaban potently prevents DVT but has been associated with bleeding complications. The simultaneous use of topical TXA and rivaroxaban in TKA has not been much investigated.

Methods

A retrospective cohort study was conducted with two consecutive groups of patients who underwent TKA. Intraoperatively, one group (RVTX group) received topical, intraarticular TXA, while the other (RV group) did not. Both groups were administered rivaroxaban postoperatively for 14 days and underwent Doppler ultrasound for DVT screening. After propensity score matching, both groups consisted of 52 patients (104 patients in total) and were compared regarding total drain output, nadir haemoglobin (Hb), maximum Hb decrease, calculated total blood loss, transfusion rate, and incidence of DVT and wound complications.

Results

Both groups showed no significant differences in the propensity-matched variables of age, sex, body mass index, American Society of Anesthesiologists physical status score, and preoperative Hb. The RVTX group showed a significantly higher nadir Hb (p < 0.001), lower drain output (p < 0.001), Hb decrease (p = 0.015), total blood loss (p < 0.001), and rate of transfusion (p < 0.001) and fewer wound complications (p = 0.027). However, the incidence of DVT (p = 1.000) did not differ significantly between the two groups, and all cases were asymptomatic.

Conclusions

The combined use of intraarticular topical TXA with rivaroxaban in patients undergoing TKA is a safe and effective method to reduce blood loss, the need for transfusion, and wound complications without elevating the risk of DVT.
Literature
1.
Fiebig E. Safety of the blood supply. Clin Orthop Relat Res. 1998;357:6–18.CrossRef
2.
Gascón P. Immunologic abnormalities in patients receiving multiple blood transfusions. Ann Intern Med. 1984;100:173.CrossRefPubMed
3.
Heddle NM, Klama LN, Griffith L, Roberts R, Shukla G, Kelton JG. A prospective study to identify the risk factors associated with acute reactions to platelet and red cell transfusions. Transfusion. 1993;33:794–7.CrossRefPubMed
4.
Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion-transmitted viral infections. N Engl J Med. 1996;334:1685–90.CrossRefPubMed
5.
Seo J-GG, Moon Y-WW, Park S-HH, Kim S-MM, Ko K-RR. The comparative efficacies of intra-articular and IV tranexamic acid for reducing blood loss during total knee arthroplasty. Knee Surg Sport Traumatol Arthrosc. 2013;21:1869–74.CrossRef
6.
Zufferey P, Merquiol F, Laporte S, Decousus H, Mismetti P, Auboyer C, et al. Do Antifibrinolytics reduce allogeneic blood transfusion in orthopedic surgery? Anesthesiology. 2006;105:1034–46.CrossRefPubMed
7.
Good L. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth. 2003;90:596–9.CrossRefPubMed
8.
Nishihara S, Hamada M. Does tranexamic acid alter the risk of thromboembolism after total hip arthroplasty in the absence of routine chemical thromboprophylaxis? Bone Jt. J. 2015;97-B(4):458–62.CrossRef
9.
Wang H, Shen B, Zeng Y. Comparison of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled and prospective cohort trials. Knee. 2014;21:987–93.CrossRefPubMed
10.
Kim Y-H, Kim J-SS. Incidence and natural history of deep-vein thrombosis after total knee arthroplasty. A prospective, randomised study. J. Bone Joint Surg. Br. 2002;84:566–70.CrossRefPubMed
11.
Stringer MD, Steadman CA, Hedges AR, Thomas EM, Morley TR, Kakkar VV. Deep vein thrombosis after elective knee surgery. An incidence study in 312 patients. J. Bone Joint Surg. Br. 1989;71:492–7.CrossRefPubMed
12.
Gómez-Outes A, Terleira-Fernández AI, Suárez-Gea ML, Vargas-Castrillón E. Dabigatran, rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment comparisons. BMJ. 2012;344:e3675.CrossRefPubMedPubMedCentral
13.
Brimmo O, Glenn M, Klika AK, Murray TG, Molloy RM, Higuera CA. Rivaroxaban use for thrombosis prophylaxis is associated with early Periprosthetic joint infection. J Arthroplast. 2016;31:1295–8.CrossRef
14.
Ricket AL, Stewart DW, Wood RC, Cornett L, Odle B, Cluck D, et al. Comparison of postoperative bleeding in Total hip and knee arthroplasty patients receiving rivaroxaban or enoxaparin. Ann Pharmacother. 2016;50:270–5.CrossRefPubMed
15.
Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. Bone Joint J. 2011;93–B:1577–85.
16.
Chen W-P. Effectiveness and safety of tranexamic acid in reducing blood loss in Total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am. 2012;94:1153.CrossRefPubMed
17.
Panteli M, Papakostidis C, Dahabreh Z, Giannoudis PV. Topical tranexamic acid in total knee replacement: a systematic review and meta-analysis. Knee. 2013;20:300–9.CrossRefPubMed
18.
Gandhi R, Evans HMK, Mahomed SR, Mahomed NN. Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty: a meta-analysis. BMC Res. Notes. 2013;6:184.CrossRefPubMedPubMedCentral
19.
Alshryda S, Sukeik M, Sarda P, Blenkinsopp J, Haddad FS, Mason JM. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J. 2014;96–B:1005–15.CrossRefPubMed
20.
Wood AM, Smith R, Keenan A, Brenkel I, Walmsley P. Using a combination of tranexamic acid and rivaroxaban in total knee replacements reduces transfusion requirements: a prospective cohort study. J Arthrosc Jt Surg. 2014;1:76–81.CrossRef
21.
Wang J-W, Chen B, Lin P-C, Yen S-H, Huang C-C, Kuo F-C. The efficacy of combined use of rivaroxaban and tranexamic acid on blood conservation in minimally invasive Total knee arthroplasty a double-blind randomized, controlled trial. J Arthroplast. 2017;32:801–6.CrossRef
22.
Wang CG, Sun ZH, Liu J, Cao JG, Li ZJ. Safety and efficacy of intra-articular tranexamic acid injection without drainage on blood loss in total knee arthroplasty: a randomized clinical trial. Int J Surg Elsevier Ltd. 2015;20:1–7.
23.
Wong J, Abrishami A, El Beheiry H, Mahomed NN, Roderick Davey J, Gandhi R, et al. Topical application of tranexamic acid reduces postoperative blood loss in Total knee arthroplasty. J Bone Joint Surg Am. 2010;92:2503–13.CrossRefPubMed
24.
Gómez-barrena E, Ortega-andreu M, Padilla-eguiluz NG, Hanna P. Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary Total knee replacement. J Bone Joint Surg Am. 2014;96:1937–44.CrossRefPubMed
25.
Turpie AGG, Fisher WD, Bauer KA, Kwong LM, Irwin MW, Kälebo P, et al. BAY 59-7939: an oral, direct factor Xa inhibitor for the prevention of venous thromboembolism in patients after total knee replacement. A phase II dose-ranging study. J Thromb Haemost. 2005;3:2479–86.CrossRefPubMed
26.
Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery. 1962;51(2):224–32. [cited 2018 Jan 3]PubMed
27.
Yen S-H, Lin P-C, Chen B, Huang C-C, Wang J-W. Topical tranexamic acid reduces blood loss in minimally invasive Total knee arthroplasty receiving rivaroxaban. Biomed Res Int. 2017;2017:1–8.CrossRef
28.
29.
Nicolaides AN, Breddin HK, Fareed J, Goldhaber S, Haas S, Hull R, et al. Prevention of venous thromboembolism. International consensus statement. Guidelines compiled in accordance with the scientific evidence. Int Angiol. 2001;20:1–37.CrossRefPubMed
30.
Kinov P, Tanchev PP, Ellis M, Volpin G. Antithrombotic prophylaxis in major orthopaedic surgery: an historical overview and update of current recommendations. Int Orthop. 2014;38:169–75.CrossRefPubMed
31.
Eriksson BI, Dahl OE, Rosencher N, Kurth AA, van Dijk CN, Frostick SP, et al. Oral dabigatran etexilate vs. subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: the RE-MODEL randomized trial. J Thromb Haemost. 2007;5:2178–85.CrossRefPubMed
32.
Lassen MR, Davidson BL, Gallus A, Pineo G, Ansell J, Deitchman D. The efficacy and safety of apixaban, an oral, direct factor Xa inhibitor, as thromboprophylaxis in patients following total knee replacement. J Thromb Haemost. 2007;5:2368–75.CrossRefPubMed
33.
Yhim HY, Lee J, Lee JY, Lee JO, Bang SM. Pharmacological thromboprophylaxis and its impact on venous thromboembolism following total knee and hip arthroplasty in Korea: a nationwide population-based study. PLoS One. 2017;12:1–15.CrossRef
34.
Bala A, Huddleston JI, Goodman SB, Maloney WJ, Amanatullah DF. Venous thromboembolism prophylaxis after TKA: aspirin, warfarin, enoxaparin, or factor Xa inhibitors? Clin Orthop Relat Res. 2017;475:2205–13.CrossRefPubMedPubMedCentral
35.
Lee G-C, Hawes T, Cushner FD, Scott WN. Current trends in blood conservation in Total knee arthroplasty. Clin Orthop Relat Res. 2005;440:170–4.CrossRefPubMed
36.
Dunn CJ. Tranexamic acid a review of its use in surgery and other indications. Drugs. 1999;57:1005–10032.CrossRefPubMed
37.
Tan J, Chen H, Liu Q, Chen C, Huang W. A meta-analysis of the effectiveness and safety of using tranexamic acid in primary unilateral total knee arthroplasty. J Surg Res. 2013;184:880–7.CrossRefPubMed
38.
Sarzaeem MM, Razi M, Kazemian G, Moghaddam ME, Rasi AM, Karimi M. Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty. J Arthroplast. 2014;29:1521–4.CrossRef
39.
Yue C, Pei F, Yang P, Xie J, Kang P. Effect of topical tranexamic acid in reducing bleeding and transfusions in TKA. Orthopedics. 2015;38:315–24.CrossRefPubMed
40.
Zhao-yu C, Yan G, Wei C, Yuejv L, Ying-ze Z. Reduced blood loss after intra-articular tranexamic acid injection during total knee arthroplasty: a meta-analysis of the literature. Knee Surg. Sport. Traumatol. Arthrosc. 2014;22:3181–90.CrossRef
Metadata
Title
Combined use of topical intraarticular tranexamic acid and rivaroxaban in total knee arthroplasty safely reduces blood loss, transfusion rates, and wound complications without increasing the risk of thrombosis
Authors
Yong Tae Kim
Min Wook Kang
Joon Kyu Lee
Young Min Lee
Joong Il Kim
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2018
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/s12891-018-2151-2

Other articles of this Issue 1/2018

BMC Musculoskeletal Disorders 1/2018 Go to the issue

Research article

The multidisciplinary treatment of osteosarcoma of the proximal tibia: a retrospective study

Research article

Update on the risks of complications after knee arthroscopy

Research article

Global postural re-education in pediatric idiopathic scoliosis: a biomechanical modeling and analysis of curve reduction during active and assisted self-correction

Research article

Identifying complications requiring re-operation following primary hip or knee arthroplasty: a consecutive series of 98 patients

Research article

Psychosocial predictors for outcome after total joint arthroplasty: a prospective comparison of hip and knee arthroplasty

Correction

Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY