Topical Tranexamic Acid Reduces Blood Loss and Transfusion Rates in Total Hip and Total Knee Arthroplasty

The objective of this study was to determine if tranexamic acid (TXA) applied topically reduced postoperative bleeding and transfusion rates after primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). Two hundred and ninety consecutive patients from a single surgeon were enrolled. In TKA, TXA solution was injected into the knee after closure of the arthrotomy. In THA, the joint was bathed in TXA solution at three points during the procedure. In both THA and TKA the TXA solution was at a concentration of 3 g TXA per 100 mL saline. The mean blood loss was significantly higher in the non-TXA patients in both TKA and THA groups. Postoperative transfusions decreased dramatically with TXA, dropping from 10% to 0%, and from 15% to 1%, in the TKA and THA groups, respectively. Topical application of TXA significantly reduces postoperative blood loss and transfusion risk in TKA and THA.     

Effects of Suture and Tourniquet on Intraoperative Kinematics in Navigated Total Knee Arthroplasty

Background

To investigate the effects of suture (soft tissue closure) and air tourniquet use on intraoperative kinematics in navigated total knee arthroplasty.

全膝关节置换术后隐性失血危险因素的分析

目的探讨全膝关节置换术后的隐性失血量,并分析影响隐性失血的相关因素。方法收集48例行初次单侧全膝关节置换术的患者,其中女42例,男6例;年龄29～79岁,平均年龄65岁。通过Gross方程,根据患者身高、体重和手术前后的红细胞压积(Hct)计算患者的总失血量,减去显性失血量后得隐性失血量。分析年龄、性别、诊断、身高、体重、BMI、术中出血量、术后引流量、术者以及止血带时间、手术时间与隐性失血的相关性。结果术中出血量为(541±271)mL(200～1700mL),术后引流量为(479±249)mL(50～1010mL),显性出血量为(1020±327)mL(440～2 220 mL),总失血量为(1 963±734)mL(92～3 926 mL),隐性失血量为(942±692)mL(-502～2 716 mL)。因此,隐性失血占总失血的48.0%。隐性失血与身高、体重都有明显正相关,但与BMI没有明显相关性,另外,隐性失血还与术后引流量呈明显负相关。结论全膝关节置换术后隐性失血量约占总失血量的一半,应引起我们足够的重视,并且术后引流量少时更不能忽视隐性失血的存在。     

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundTourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes.MethodsPatients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected.ResultsVisual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent.ConclusionThis study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.     

全膝关节置换术隐性失血的初步研究

目的研究人工全膝关节置换术(totalkneearthroplasty,TKA)的隐性失血。方法对73例TKA患者进行回顾性分析,通过Gross方程推算术后平均隐性失血量。结果TKA组中使用自体血回输患者的总失血量为1625ml,隐性失血量为774ml(48%);未使用自体血回输患者的总失血量是1345ml,隐性失血量是783ml(58%);实际上两组的隐性失血相差不大。结论TKA隐性失血量占总失血量的比例为52%,且使用自体血回输不能完全满足机体恢复体循环的需要,在围手术期要特别注意及时补充血容量。     

Blood Transfusion can be Avoided in Single-Anesthetic Bilateral Total Knee Arthroplasty

BackgroundFemale gender and surgical drain use have been associated with an increased transfusion risk following single-anesthetic bilateral total knee arthroplasty (SBTKA). This study evaluated allogenic blood transfusion rates among female and male patients undergoing SBTKA with intraoperative tourniquet, tranexamic acid and contemporary blood transfusion thresholds but without surgical drain use.MethodsWe performed a retrospective electronic medical record review for 125 consecutive patients undergoing SBTKA (250 knees) between May 1, 2015 and July 10, 2021. Patient demographic characteristics (age, gender, body mass index, American Society of Anesthesiologists), preoperative and postoperative hemoglobin levels, perioperative transfusions, operative time, and hospital length of stay were compared between 76 female (60.8%) and 49 male (39.2%) patient cohorts using paired Student’s t-test or Fisher’s exact test with a P value <.05 for significance.ResultsNo patient in either gender-based cohort received a perioperative allogeneic or autologous blood transfusion (P = 1). There were no significant differences in patient demographic features or medical comorbidities. Male patients had significantly higher mean preoperative (14.7 versus 13.7 g/dL, P < .01) and postoperative (12.7 versus 11.8 g/dL, P < .01) hemoglobin levels and a shorter mean hospital length of stay (2.5 versus 3.0 days, P < .01). There was no difference in the mean operative time (154.7 versus 150.7 minutes, P = .34) or change in the hemoglobin level (2.1 versus 1.9 g/dL, P = .27).ConclusionSBTKA can be performed with a limited risk of perioperative transfusion with a combination of intraoperative tourniquet, tranexamic acid, conservative blood transfusion criteria, and avoidance of postoperative drain use. Study results were not influenced by patient gender.Level of evidenceThis is a level III, retrospective cohort study.     

Optimized Tourniquet Use in Primary Total Knee Arthroplasty: A Comparative,Prospective, and Randomized Study

BackgroundThe results of recent studies investigating tourniquet (TNQ) use for knee arthroplasty are controversial. Therefore, this study aimed to compare patients undergoing total knee arthroplasty who did not have a TNQ to those in whom an optimized TNQ protocol was applied.MethodsWe prospectively evaluated 127 patients who had knee osteoarthritis who had undergone total knee arthroplasty and randomized them into two groups: “without TNQ” and “optimized TNQ” (TNQ inflation before skin incision, deflation after cementing, with pressure one hundred millimeters of mercury above the systolic blood pressure, and without articular suction drain usage). The means of surgery and TNQ duration, blood loss, number of blood transfusions, degree of pain, edema, range of motion (ROM), functional score over time, and postoperative complications were compared between the groups. Statistical significance was set at P < .05.ResultsNo significant differences were found in terms of surgical timing, blood loss, thigh and knee pain, edema, ROM, functional scores, and complications between the “without TNQ” and “optimized TNQ” groups.ConclusionThe use of an optimized TNQ in primary total knee arthroplasty presents similar clinical results to surgery without a TNQ and did not increase the incidence of postoperative complications. Its use allowed surgery to occur with the benefits of a clean and dry surgical field provided by TNQ without increasing procedure-related comorbidities.     

Effect of Different Tourniquet Pressure on Postoperative Pain and Complications After Total Knee Arthroplasty: A Prospective,Randomized Controlled Trial

BackgroundTourniquet pressure inflation is commonly selected between 100 and 150 mm Hg above the systolic blood pressure (SBP). Given the lack of evidence to support a given inflation pressure, our study aimed to ascertain the lowest tourniquet pressure that facilitated total knee arthroplasty (TKA) and resulted in the least postoperative pain and complications.MethodsIn a double-blind, randomized controlled trial of patients scheduled for unilateral primary TKA, 150 were assigned to use tourniquet pressures of SBP + 75 mm Hg (group I), SBP + 100 mm Hg (group II), and SBP + 150 mm Hg (group III). The quality of the bloodless field, total blood loss, and limb swelling were determined perioperatively. Clinical outcomes were evaluated by visual analog scale for pain at thigh and surgical site, serum creatinine phosphokinase levels, wound complications, range of motion, and Knee Society Score.ResultsVisual analog scale for pain at thigh and surgical site were lowest in group I (P < .01) and highest in group III (P < .01). However, the quality of bloodless field at the tibial cutting surface was significantly better in group III compared to group I/II but not at the femoral cutting surface. The total blood loss and limb swelling showed no difference among 3 groups. Postoperative serum creatinine phosphokinase levels at 24 and 48 hours and wound complications in group III were significantly higher than group I (P < .01) and group II (P < .01). Nevertheless, postoperative knee range of motion and Knee Society Score were not significantly different among 3 groups.ConclusionPost TKA, the lowest tourniquet pressure was associated with significantly less postoperative tourniquet and surgical site pain, muscle damage, and wound complications.     

Oral Tranexamic Acid Reduces Transfusions in Total Knee Arthroplasty

Background

Tranexamic acid (TXA) reduces intraoperative blood loss and transfusions in patients undergoing total knee arthroplasty. Although numerous studies demonstrate the efficacy of intravenous and topical TXA in these patients, few demonstrate the effectiveness and appropriate dosing recommendations of oral formulations.

骨性关节炎全膝关节置换术中切除滑膜对失血量及膝关节功能的影响

目的:探讨骨性关节炎全膝关节置换术中切除滑膜对失血量和膝关节功能的影响。方法:选取初次骨性关节炎全膝关节置换术患者180例,随机分成观察组和对照组各90例。观察组在全膝关节置换手术中切除滑膜,对照组保留滑膜,观察两组手术失血量、手术时间、和手术前后的疼痛情况以及术后膝关节临床和功能评分。结果:观察组手术显性失血量(750.9±253.7)mL、隐性出血量(722.8±213.3)mL、理论总出血量(1557.2±346.8)mL和手术时间(111.3±23.9)min均明显高于对照组显性失血量(543.2±223.6)mL、隐性失血量(536.1±192.4)mL、理论总失血量(1086.7±242.9)mL和手术时间(90.6±20.2)min(P0.05);两组手术后3 d、12周和1年时的VAS评分均明显低于手术前,差异均有统计学意义(P0.05);但两组间比较差异无统计学意义(P0.05);两组术后12周和术后1年美国膝关节协会评分标准(AKSS)临床评分和功能评分比较,差异无统计学意义(P0.05);观察组术后不良反应和感染发生率为11.11%,对照组3.33%(P0.05)。结论:骨性关节炎全膝关节置换术中切除滑膜,可明显增加失血量和感染风险,但未能显著促进膝关节功能改善的作用。     

Comparing the Effect of Tourniquet vs Tourniquet-Less in Simultaneous Bilateral Total Knee Arthroplasties

Background

Total knee arthroplasty (TKA) is a commonly performed procedure worldwide for the treatment of knee joint disease. Tourniquet is frequently used during the entire procedure to reduce blood loss and increase surgical comfort. On the other hand, tourniquet-related complications exist, and there are still controversies whether benefits outweigh the risks.

Comparison Between Intravenous and Intra-articular Regimens of Tranexamic Acid in Reducing Blood Loss During Total Knee Arthroplasty

Tranexamic acid is an antifibrinolytic drug used widely to prevent bleeding. Its use in reducing bleeding during total knee arthroplasty surgery is well proven but there is no final consensus regarding the regimen. The purpose of our study was to compare the effectiveness of intravenous and intra-articular regimen of tranexamic acid during the total knee arthroplasty surgery. A total of 40 patients were received three doses of intravenous tranexamic acid during total knee arthroplasty surgery. Intra-articular tranexamic acid was used in 40 patients during the surgery. We concluded that intra-articular tranexamic acid is equally effective as three dose intravenous regimen in reducing blood loss during total knee arthroplasty surgery.     

A Prospective Study on Role of Tranexamic Acid in Reducing Postoperative Blood Loss in Total Knee Arthroplasty and Its Effect on Coagulation Profile

Total knee arthroplasty(TKA) is associated with extensive postoperative blood loss. Despite various studies proving the efficacy of Tranexamic Acid (TEA) with single or multiple boluses of different sizes with or without subsequent infusions, no consensus has been reached on the dose of tranexamic acid to be administered or the duration of treatment. In this study, we have investigated in a homogenous healthy population undergoing total knee arthroplasty, if administration of a high dose of tranexamic acid has a blood sparing effect. They were found to be significant with high power concluding a decrease in total blood loss in patients who were administered Tranexamic Acid (TEA) during Total Knee Arthroplasty (TKA). A dose regimen of 15 mg/kg every 8 h for 24 h would seem appropriate as longer administration of TEA was not accompanied by further reduction in blood loss.     

Use of Tourniquet During Knee Arthroplasty in Patients With Radiographic Arterial Calcifications

BackgroundUse of tourniquet during total knee arthroplasty (TKA) in patients with radiographic arterial calcifications is controversial. Intimal arterial calcifications are feared to be associated with ischemic complications such as delayed wound healing and arterial thrombosis, whereas medial calcifications stiffen the arterial wall, possibly leading to tourniquet failure and increased blood loss.MethodsWe conducted a prospective cohort study to determine the incidence of tourniquet failure (inflated up to 300 mm Hg), blood transfusions, wound healing, and ischemic complications in thighs with and without arterial calcifications on preoperative radiographs, in 2548 consecutive primary TKAs conducted in our unit over a 5-year period. Eighty-six thighs showed vascular calcifications: 58 medial and 28 intimal.ResultsThighs with vascular calcifications had higher risk of tourniquet failure as compared to those without calcifications (P < .001), but with no significant increase in incidence of blood transfusions. All cases of tourniquet failure in the calcification group occurred in thighs with medial calcifications, whereas all cases of tourniquet failure in the control group occurred in obese patients. There was no difference in wound healing and ischemic complications in limbs with and without arterial calcifications.ConclusionThe presence of arterial calcifications on preoperative radiographs increases the risk of tourniquet failure at 300 mm Hg in patients undergoing TKA, with no significant increase in rate of blood transfusions, wound healing or ischemic complications.     

The Fragility of Tourniquet Use in Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials

BackgroundPhysicians utilize P-values to interpret clinical trial data and guide patient-care decisions. Fragility analysis assesses the stability of statistical findings in relation to outcome event reversals. This study assessed the statistical fragility of recent randomized controlled trials (RCTs) investigating tourniquet use in total knee arthroplasty (TKA).MethodsWe queried PubMed, EMBASE, and MEDLINE for RCTs comparing outcomes in TKA based on tourniquet use. Fragility index (FI) and reverse fragility index (reverse FI) were calculated – for significant and nonsignificant outcomes, respectively – as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) was calculated by dividing the FI or reverse FI by the sample size. Median overall FI and FQ were calculated for all included outcomes, and sub-analyses were performed by reported significance. The literature search yielded 23 studies reporting 91 total dichotomous outcomes.ResultsOverall median FI was 4 with an interquartile range (IQR) of 3 to 6. Overall median FQ was 0.0476 (IQR 0.0291 to 0.0867). A total of 11 outcomes were statistically significant with a median FI and FQ of 2 (IQR 1.5 to 5) and 0.0200 (IQR 0.0148 to 0.0484), respectively. There were 80 outcomes that were nonsignificant with a median reverse FI of 4 (IQR 3 to 6). Loss to follow-up was greater than the median FI in 17.6% of outcomes.ConclusionAltering a small number of outcomes is often sufficient to reverse findings in RCTs evaluating tourniquet use in TKA. We recommend including fragility analyses to increase reliability in the interpretation of study conclusions.     

Bone Wax Is Effective in Reducing Blood Loss After Total Knee Arthroplasty

Background

Total knee arthroplasty (TKA) is associated with major blood loss and blood transfusion is often required. This study aimed to evaluate the efficacy of bone wax in reducing blood loss and transfusion rates after TKA.

The Efficacy Comparison of Tranexamic Acid for Reducing Blood Loss in Total Knee Arthroplasty at Different Dosage Time

Background

This study aimed to compare the efficacy of intravenous administration of tranexamic acid for reducing blood loss in total knee arthroplasty at different dosage time.

The Effect of Tranexamic Acid on Blood Loss and Transfusion Rate in Primary Total Knee Arthroplasty

Allogeneic blood transfusions remain common in primary total knee arthroplasty. We reviewed our experience with 2269 consecutive primary total knee arthroplasties in 2069 patients over a 3.5 year period. In our cohort, 1838 received no TXA, 330 received TXA via IV infusion, and 130 had TXA applied topically. The need for blood transfusion, as well as hematocrit levels immediately after surgery in the recovery room and the day of discharge were recorded. Tranexamic acid infusion demonstrated a statistically significant decrease in blood transfusion (P = 0.001), as did topical application of TXA (P = 0.019). The transfusion rate without TXA was 6.5% (120/1839) but only 0.3% (1/330) with TXA infusion. There were no transfusions (0/130) with topical TXA. Statistical differences were also noted in both immediate post operative and day of discharge hematocrit levels in patients having TXA infusion while those values for patients with TXA irrigation failed to obtain statistical significance. No significant change in the rate of symptomatic deep venous thrombosis or pulmonary embolism was noted.