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BMC Musculoskeletal Disorders

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Open Access 01-12-2016 | Research article

Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial

Authors: P Pinsornsak, S Rojanavijitkul, S Chumchuen

Published in: BMC Musculoskeletal Disorders | Issue 1/2016

Abstract

Background

Intravenous tranexamic acid (IV TXA) is one of the most effective agents in use for reducing blood loss following total knee arthroplasty (TKA) but its safety regarding venous thromboembolic events (VTEs) remains in question. The direct, local application of TXA may reduce systemic toxicity whilst maintaining good or better bleeding control compared to IV TXA. The topical application of TXA via Hemovac drains has been reported previously with good results. However, there are no data on peri-articular TXA injections during TKA.

Methods

We conducted an open randomized, pilot study of peri-articular vs. IV TXA in 60 patients undergoing TKA. 30 patients received either: (i) 750 mg peri-articular TXA into the medial, lateral capsules and the quadriceps tendon prior to capsular closure and tourniquet deflation (group1), or (ii) 750 mg of IV TXA just before tourniquet deflation. Blood loss in the hemovac drain and hemoglobin (Hb) concentrations were measured at 24 and 48 h (h), and the number of blood transfusions and leg circumference measurements were recorded.

Results

At 48 h, the total blood loss in the hemovac drain was 445 mL in group 1 vs. 520 mL in group 2 (p = 0.081) and the corresponding declines in Hb were 1.85 g/dL vs. 1.87 g/dL (p = 0.84). 16 patients received blood transfusions: 9 vs. 7 in groups 1 and 2, respectively (p = 0.928). There were no differences in thigh and lower leg circumferences, pain scores, knee flexion at discharge date and lengths of hospital stay. There were no clinically detected venous thromboembolic events.

Conclusion

This pilot study has shown promising results for peri-articular TXA during TKA. Additional, larger studies are needed to confirm our results and be powered to show differences in efficacy and safety of peri-articular vs. IV TXA.

Trial registration

ClinicalTrials.gov Identifier NCT02829346. Retrospectively registered: 07/11/2016.

Sinclair KC, Clarke HD, Noble BN. Blood management in total knee arthroplasty: a comparison of techniques. Orthopedics. 2009;32:19.CrossRefPubMed

Gonzalez-Porras JR, Colado E, Conde MP, Lopez T, Nieto MJ, Corral M. An individualized pre-operative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty. Transfus Med. 2009;19:35–42.CrossRefPubMed

Parvizi J, Diaz-Ledezma C. Total knee replacement with the use of a tourniquet: more pros than cons. Bone Joint J. 2013;95-B(Supple A):133–4.CrossRefPubMed

Sabatini L, Trecci A, Imarisio D, Uslenghi MD, Bianco G, Scagnelli R. Fibrin tissue adhesive reduces postoperative blood loss in total knee arthroplasty. J Orthop Traumatol. 2012;13:145–51.CrossRefPubMedPubMedCentral

Pitta M, Zawadsky M, Verstraete R, Rubinstein A. Intravenous administration of tranexamic acid effectively reduces blood loss in primary total knee arthroplasty in a 610-patient consecutive case series. Transfusion. 2016;56(2):466–71.CrossRefPubMed

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: a randomized, controlled trial. J Bone Joint Surg Am. 2010;92:2503–13.CrossRefPubMed

Aggarwal AK, Singh N, Sudesh P. Topical vs Intravenous Tranexamic Acid in Reducing Blood Loss After Bilateral Total Knee Arthroplasty: A Prospective Study. J Arthroplasty. 2015 Dec 21. doi:10.1016/j.arth.2015.12.033. [Epub ahead of print]

Benoni G, Lethagen S, Fredin H. The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res. 1997;85:195–206.CrossRefPubMed

Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999;57:1005–32.CrossRefPubMed

10.

Eubanks JD. Antifibrinolytics in major orthopaedic surgery. J Am Acad Orthop Surg. 2010;18:132–8.CrossRefPubMed

11.

Kluft C, Verheijen JH, Jie AF, Rijken DC, Preston FE, Sue-Ling HM, et al. The postoperative fibrinolytic shutdown: a rapidly reverting acute phase pattern for the fast-acting inhibitor of tissue-type plasminogen activator after trauma. Scand J Clin Lab Invest. 1985;45:605–10.CrossRefPubMed

12.

Murphy WG, Davies MJ, Eduardo A. The haemostatic response to surgery and trauma. Br J Anaesth. 1993;70:205–13.CrossRefPubMed

13.

Charoencholvanich K, Siriwattanasakul P. Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial. Clin Orthop Relat Res. 2011;469:2874–80.CrossRefPubMedPubMedCentral

14.

Orpen NM, Little C, Walker G, Crawford EJ. Tranexamic acid reduces early postoperative blood loss after total knee arthroplasty; a prospective randomized controlled trial of 29 patients. Knee. 2006;13:106–10.CrossRefPubMed

15.

Ortega-Andreu M, Pérez-Chrzanowska H, Figueredo R, Gómez-Barrena E. Blood loss control with two doses of tranexamic Acid in a multimodal protocol for total knee arthroplasty. Open Orthop J. 2011;5:44–8.CrossRefPubMedPubMedCentral

16.

Mannucci PM. Hemostatic drugs. N Engl J Med. 1998;339:245–53.CrossRefPubMed

17.

Mannucci PM. Prevention and treatment of major blood loss. N Engl J Med. 2007;356:2301–11.CrossRefPubMed

18.

Ishida K, Tsumura N, Kitagawa A, Hamamura S, Fukuda K, Dogaki Y, et al. Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty. Int Orthop. 2011;35:1639–45.CrossRefPubMedPubMedCentral

19.

Maniar RN, Kumar G, Singhi T, Nayak RM, Maniar PR. Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients. Clin Orthop Relat Res. 2012;470:2605–12.CrossRefPubMedPubMedCentral

20.

Roy SP, Tanki UF, Dutta A, Jain SK, Nagi ON. Efficacy of intra-articular tranexamic acid in blood loss reduction following primary unilateral total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012;20:2494–501.CrossRefPubMed

21.

Wang H, Shen B, Zeng Y. Blood Loss and Transfusion After Topical Tranexamic Acid Administration in Primary Total Knee Arthroplasty. Orthopedics. 2015;38(11):e1007–16. doi:10.3928/01477447-20151020-10.CrossRefPubMed

22.

Spreng UJ, Dahl V, Hjall A, Fagerland MW, Ræder J. High-volume local infiltration analgesia combined with intravenous or local ketorolac + morphine compared with epidural analgesia after total knee arthroplasty. Br J Anaesth. 2010;105:675–82.CrossRefPubMed

23.

Manor D, Sadeh M. Muscle fiber necrosis induced by intramuscular injection of drugs. Br J Exp Pathol. 1989;70:457–62.PubMedPubMedCentral

24.

Pinsornsak P, Chumchuen S. Can a modified Robert Jones bandage after knee arthroplasty reduce blood loss? A prospective randomized controlled trial. Clin Orthop Relat Res. 2013;471(5):1677–81.CrossRefPubMedPubMedCentral

25.

Kagoma YK, Crowther MA, Douketis J, Bhandari M, Eikelboom J, Lim W. Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials. Thromb Res. 2009;123:687–96.CrossRefPubMed

26.

Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg (Br). 2011;93:1577–85.CrossRef

27.

Gandhi R, Evans HM, 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

Title: Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial
Authors: P Pinsornsak
S Rojanavijitkul
S Chumchuen
Publication date: 01-12-2016
Publisher: BioMed Central
Published in: BMC Musculoskeletal Disorders / Issue 1/2016
Electronic ISSN: 1471-2474
DOI: https://doi.org/10.1186/s12891-016-1176-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial

Abstract

Background

Methods

Results

Conclusion

Trial registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Trial registration

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