Suction drainage in total knee replacement does not influence early functional outcomes or blood loss: a randomized control trial
Maliarov A, Newman N, Sabouret P, Al-Shakfa F, Chergui S, Lavoie F
Arthroplasty (London, England). 2023;5(1):8
INTRODUCTION The use of wound drainage following total knee arthroplasty (TKA) remains controversial. The purpose of this study was to evaluate the impact of suction drainage on early postoperative outcomes in patients who underwent TKA with concomitant administration of intravenous tranexamic acid (TXA). METHOD One hundred forty-six patients undergoing primary TKA with systematic intravenous TXA were prospectively selected and randomly divided into two groups. The first "Study group" (n = 67) received no suction drain and the second "Control" group (n = 79) had a suction drain. Perioperative hemoglobin levels, blood loss, complications, and length of hospital stay were assessed in both groups. Preoperative and postoperative range of motion and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were also compared at a 6-week follow-up. RESULTS The study group was found to have higher hemoglobin levels preoperatively and during the first two days following surgery, and no difference was found between the groups on the third day. No significant discrepancies at any time were found between groups in terms of blood loss, length of hospitalization, knee range of motion, and KOOS score. Complications requiring further treatment were observed in one patient from the study group and ten patients from the control group. CONCLUSION The use of suction drains after TKA with TXA did not alter early postoperative outcomes.
Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis
Tripathy SK, Varghese P, Kumarasamy AKN, Mishra NP, Neradi D, Jain M, Sarkar S, Sen RK
Indian journal of orthopaedics. 2023;57(1):33-43
PURPOSE Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients. METHODS Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality). RESULTS There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I (2) = 73%). The TXA group had significantly decreased total blood loss (MD - 100.31; 95% CI - 153.79, - 46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I (2) = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03). CONCLUSIONS Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients. LEVEL OF EVIDENCE III.
Efficacy and safety of tranexamic acid in elderly patients with femoral neck fracture treated with hip arthroplasty: A systematic review and meta-analysis
Zhao YK, Zhang C, Zhang YW, Li RY, Xie T, Bai LY, Chen H, Rui YF
Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. 2023
BACKGROUND Elderly patients with femoral neck fracture have high perioperative blood loss according to the trauma and hip arthroplasty surgery. Tranexamic acid is a fibrinolytic inhibitor and has been widely used in hip fracture patients to against perioperative anemia. The aim of the present meta-analysis was to evaluate the efficacy and safety of Tranexamic acid (TXA) in elderly patients with femoral neck fracture undergoing hip arthroplasty. METHODS We performed search using Pubmed, EMBASE, Cochrane Reviews, and Web of Science databases to identify all relevant research studies published from inception to June 2022. Randomized controlled studies and high-quality cohort studies that reported the perioperative use of TXA in patients with femoral neck fractures treated with arthroplasty, and made a comparison with the control group were included. Meta-analysis was performed using Review Manager 5.3 to assess the efficacy and safety of TXA. Subgroup analysis was conducted to further investigate the impact caused by surgery types and administration routes on the efficacy and safety outcomes. RESULTS Five randomized controlled trials (RCTs) and eight cohort studies published from January 2015 to June 2022 were included in this meta-analysis. The results showed significant reductions in the rate of allogeneic blood transfusion, total blood loss (TBL) and postoperative hemoglobin (Hb) drop in the TXA group compared with the control group, while no significant difference was found in the intraoperative blood loss, postoperative drainage, hospital length of stay (LOS), re-admission rate, and wound complications between the two groups. The incidence of thromboembolic events and mortality showed no significant difference. Subgroup analysis indicated that surgery types and administration routes did not change the overall tendency. CONCLUSION The current evidence shows that both intravascular administration (IV) and topical administration of TXA can significantly decrease the perioperative transfusion rate and TBL without increasing the risk of thromboembolic complications in elderly patients with femoral neck fracture.
The Use of Tranexamic Acid in Hip Fracture Surgery-A Systematic Review and Meta-analysis
Agius C, Cole E, Mifsud MG, Vasireddy A
Journal of orthopaedic trauma. 2022;36(12):e442-e448
OBJECTIVES To analyze the effect of intravenous tranexamic acid (TXA) on blood transfusion requirements in adult patients undergoing hip fracture surgery. Secondary aim was to evaluate the safety by assessing thromboembolic events. DATA SOURCES Cochrane Central Register of Controlled Trials, Medline, PubMed, and Embase were searched for randomized controlled trials published in English from 2010. STUDY SELECTION Studies eligible for inclusion were randomized controlled trials that analyzed the use of intravenous TXA on blood transfusion requirement in hip fracture surgery. DATA EXTRACTION Titles and abstracts were screened and assessed for eligibility by 2 independent reviewers. Quality and risk of bias was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach and the Cochrane risk-of-bias tool (RoB2). DATA SYNTHESIS Meta-analysis with random and fixed effect models was performed. Risk ratio (RR) was calculated for dichotomous outcomes and estimated with a 95% confidence interval (CI). For continuous data, the risk difference (RD) was estimated with a 95% CI. RESULTS A total of 13 trials involving 1194 patients were included. Pooled results showed that patients in the TXA group had significantly lower transfusion requirements (RR 0.50, 95%CI 0.30-0.84, P = 0.009). Similar findings were observed in the subcohort of patients with transfusion threshold of Hb < 8g/dL, (RR 0.42, 95%CI 0.31-0.56, P < 0.0001). This risk reduction was not observed in the subcohort of patients with transfusion threshold of Hb 8.1-10g/dL who received TXA (RR 0.77, 95%CI 0.51-1.18, P = 0.23) and no statistically significant differences were found for total thromboembolic events (RR 0.01, 95%CI -0.02-0.04, P = 0.47). CONCLUSION This meta-analysis demonstrated that intravenous TXA reduced blood transfusion rates and did not increase the risk of thromboembolic events. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Arthroscopic Rotator Cuff Repair Performed with Intraarticular Tranexamic Acid. Could it Provide Improved Visual Clarity and less Postoperative Pain? A prospective, double blind, randomized study of 63 patients
Bildik C, Pehlivanoglu T
Journal of shoulder and elbow surgery. 2022
BACKGROUND Tranexamic acid (TXA) was widely used in orthopedic surgery with the aim to reduce intra-/postoperative bleeding and bleeding related complications. The aim of the present study was to assess, whether intra-articular use of TXA during arthroscopic rotator cuff tear (RCT) repair could improve the visual clarity, shorten the duration of operation and provide superior pain management as compared to placebo. METHODS This study was conducted as prospective, randomized, double-blinded and placebo controlled. Patients with MRI confirmed RCT, above the age of 18 and a history of failed conservative treatment for at least 6 months were included. Patients with a history of coagulopathy, cardiac-renal-hepatic disease and those with a history of conservative treatment less than 6 months and acute RCT were excluded. Visual clarity as the primary outcome was assessed by using arthroscopic visual scale comprising 5 grades ranging from grade 1: best visual clarity, grade 5: worst visual clarity (need to do open surgery) after the procedure by the operating surgeon every 10 minutes throughout the video of the operation. Secondary outcomes were duration of operations and postoperative pain scores. RESULTS 63 patients were enrolled and randomized into two groups with similar demographic data (age-sex-intraoperative mean arterial pressure): TXA Group comprised 32 patients with a mean age of 56.46. Placebo group comprised 31 patients with a mean age of 57.83. TXA group was reported to have significantly superior visual clarity (mean arthroscopic visual score 1.5±0.5 vs. 2.86±1.7, p=.000) with significantly higher percentage of grade 1 visual clarity (78.1% vs. 32.2%, p=.000) and lower percentage of grade 4 visual clarity (0% vs. 3.2%, p=.003). Grade 5 visual clarity was recorded in none of the patients in either group. TXA group was found to have significantly shorter duration of operation (55.73 vs. 67.26, p=.001) and superior pain scores at the 8(th) and 24(th) postoperative hour (2.3 vs 3.6 and 1.6 vs. 2.4, p=.002 and p=.000). No complications were recorded in either of the groups. CONCLUSIONS The present study concluded, that during arthroscopic rotator cuff repair procedures, intra-articular use of TXA was able to provide superior arthroscopic visual clarity, while shortening total durations of operations significantly and providing significantly superior pain-management at the first 8(th) and 24(th) postoperative hours as compared to placebo. The present study also underlined the safety and efficacy of intra-articular TXA use in arthroscopic rotator cuff repair.
Clinical trial to determine whether the timing of tranexamic acid administration influences perioperative bleeding in total knee arthroplasty
Luis C, Pardo A, Moreno CE, Teixell C, Santiveri X, Bisbe E
Revista espanola de anestesiologia y reanimacion. 2022
BACKGROUND AND OBJECTIVES The ideal timing of tranexamic acid administration in total knee arthroplasty with tourniquet remains unclear. Our primary objective was to prove if administering it before surgical incision, instead of before releasing the tourniquet, reduces postoperative bleeding. A second objective was to determine whether a second dose reduces post-operative bleeding. MATERIAL AND METHODS A prospective, double-blind clinical trial was performed on 212 patients scheduled for total knee arthroplasty. They were randomised into 4 groups. Tranexamic acid was administered before the surgical incision in "pre-induction groups" (1 and 2), and just before the tourniquet release in "pre-release groups" (3 and 4). Groups 2 and 4 received a second dose 3h post-surgery. Main outcome was postoperative bleeding (visible blood loss and calculated total bleeding). Secondary outcomes were haemoglobin variations, complications and transfusion rate. RESULTS The mean calculated total bleeding was 1563ml (95%CI: 1445-1681) in preinduction groups versus 1576ml (95%CI: 1439-1713) in pre-release groups (P=0.9); 1579ml (95%CI: 1452-1706) in single-dose groups versus 1559ml (95%CI: 1431-1686) in double-dose groups (P=0.82). One patient was transfused. The mean haemoglobin at discharge was 10.4g/dl (95%CI: 10.2-10.7) in singledose groups versus 10.8 (95%CI: 10.6-11.1) in double-dose groups (P=0.06). CONCLUSIONS There were no differences in bleeding or transfusion regarding the time of tranexamic acid administration. The second dose had not impact on outcomes. TRIAL REGISTRATION EudraCT 2016-000071-24.
Personalized tourniquet pressure may be a better choice than uniform tourniquet pressure during total knee arthroplasty: A PRISMA-compliant systematic review and meta-analysis of randomized-controlled trials
Sun C, Yang X, Zhang X, Ma Q, Yu P, Cai X, Zhou Y
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BACKGROUND Pneumatic tourniquets are widely used in total knee arthroplasty (TKA). Some surgeons prefer a uniform tourniquet inflation pressure (UTIP) for all patients; others use personalized tourniquet inflation pressures (PTIP) based on systolic blood pressure and limb occlusion pressure. However, no consensus exists regarding the optimal mode of inflation pressure during TKA. This review aimed to appraise if personalized tourniquet inflation pressures are better than uniform tourniquet inflation. METHODS The databases (Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang) were searched on March 2021 to systematically identify and screen the literature for randomized controlled trials involving PTIP and UTIP during total knee arthroplasty. RESULTS Thirteen randomized controlled trials, involving 1204 TKAs (1201 patients) were included in the systematic review. The meta-analysis identified a trend toward less visual analogue scale (VAS) score at rest with PTIP group at 1 day (P = .002), 2 to 3 days (P = .01), and less VAS score at activity 1 day (P < .0001), 2 to 3 days after the operation (P < .00001), and discharge (P < .0001). No significant difference was found between the groups in terms of VAS score at rest when discharge (P = 1.0). We also found no significant difference in terms of intraoperative blood loss (P = .48), total blood loss (P = .15), lower limb vein thrombosis (P = .42), and thigh bullae (P = .17). However, in the PTIP group, we found a significant higher hospital for special surgery (HSS) score (P = .007), broader knee Range of motion (P = .02), less rate of thigh ecchymosis (P = .00001), and shorter thigh circumference at 1 day (P = .006), 2 to 3 days (P = .0005), and discharge (P = .02). CONCLUSION PTIP provides a similar bloodless surgical field compared with the conventional UTIP. Furthermore, PTIP provides less pain intensity, thigh circumference, rate of thigh ecchymosis, higher hospital for special surgery, and better initial recovery of knee flexion in total knee arthroplasty. Therefore, we recommend using a PTIP method during TKA. More adequately powered and better-designed randomized controlled trials studies with long-term follow-up are required to produce evidence-based guidelines regarding the PTIP method.
Impact of tourniquet during total knee arthroplasty when tranexamic acid was used: a meta-analysis of randomized controlled trials
Sun C, Zhang X, Ma Q, Tu Y, Cai X, Zhou Y
Journal of orthopaedic surgery and research. 2022;17(1):18
INTRODUCTION The efficacy of tourniquet use during primary total knee arthroplasty (TKA) is thought to reduce intraoperative blood loss, improve surgical exposure, and optimize cement fixation. Tranexamic acid (TXA) use can decrease postsurgical blood loss and transfusion requirements. This review aimed to appraise the effects of tourniquet use in TKA for patients with tranexamic acid use. METHODS A meta-analysis was conducted to identify relevant randomized controlled trials involving TXA plus a tourniquet (TXA-T group) and use of TXA plus no tourniquet (TXA-NT group) in TKA. Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database were searched from 2010 through October 2021. RESULTS We identified 1720 TKAs (1690 patients) assessed in 14 randomized controlled trials. Compared with the TXA-NT group, the TXA-T group resulted in less intra-operative blood loss (P < 0.00001) and decreased duration of surgery (P < 0.00001), however more hidden blood loss (P = 0.0004) and less knee range of motion (P < 0.00001). No significant differences were found between two groups in terms of decrease in hemoglobin (P = 0.84), total blood loss (P = 0.79), transfusion rate (P = 0.18), drainage volume (P = 0.06), Visual Analogue Scale (VAS) at either the day of surgery (P = 0.2), 1 day (P = 0.25), 2 day (P = 0.39), 3 day (P = 0.21), 5 day (P = 0.21), 7 day (P = 0.06) or 1 month after surgery (P = 0.16), Hospital for Special Surgery (HSS) score at either 7 day (P = 0.10), 1 month (P = 0.08), 3 month (P = 0.22) or 6 month after the surgery (P = 0.92), Knee circumference (P = 0.28), length of hospital (P = 0.12), and complications such as intramuscular venous thrombosis (P = 0.81), deep venous thrombosis (P = 0.10), superficial infection (P = 0.45), deep wound infection (P = 0.64), and delayed wound healing (P = 0.65). CONCLUSION No big differences could be found by using or not tourniquet when use the TXA, though some benefits are related to operation time and less intra-operative blood loss by using tourniquet and TXA, Using the tourniquet was related to more hidden blood loss and less knee range of motion. More adequately powered and better-designed randomized controlled trials (RCTs) studies with long-term follow-up are required to validate this study.
A Randomized Controlled Study on the Use of Tourniquet in Primary Total Knee Arthroplasty
Zhang C, Yan CH, Chan PK, Fu H, Chiu KY
The journal of knee surgery. 2022
BACKGROUND The use and the optimal timing of tourniquet during primary total knee arthroplasty (TKA) is controversial. Most previous studies failed to show clinically significant differences in different strategies. The aim of this study was to determine how three strategies of tourniquet application affect the outcome in TKA patients. METHODS This was a prospective randomized controlled study. Patients who undergo TKA were randomized into one of the three groups (1:1:1 ratio): tourniquet inflated from skin incision to cement hardening, tourniquet from cement application to hardening, and tourniquet from skin incision to skin closure. The perioperative blood loss, limb swelling, and complications were recorded. The level of hemoglobin, hematocrit, C-reactive protein (CRP), interleukin (IL)-6, creatine kinase (CK), and lactate dehydrogenase (LDH) were determined. Patients' thigh and TKA wound pain, Knee Society knee score (KSKS) and Knee Society functional assessment (KSFA) scores, and rehabilitation parameters were evaluated. RESULTS A total of 90 patients were enrolled. The baseline characteristics were comparable. We only found significant difference in the intraoperative blood loss (skin to cement: 58.7 ± 36.1 mL, cement-only: 147.8 ± 107.9 mL, skin to skin: 16.3 ± 13.1 mL, p < 0.0001). There were no statistical differences in postoperative drainage, thigh/knee circumference, change of hemoglobin/hematocrit, CRP, IL-6, CK, and LDH on day 1 to day 4 after surgery. The thigh/TKA wound Visual Analogue Scale scores, KSKS score, KSFA score, and rehabilitation parameters were not significantly different at up to 6-month follow-up. No thromboembolic events were noted. CONCLUSION Our results revealed that there was no best tourniquet strategy in TKA. Different tourniquet methods can be utilized based on surgeon preference without affecting outcomes.
Combination of Intravenous and Intra-Articular Application of Tranexamic Acid and Epsilon-Aminocaproic Acid in Primary Total Knee Arthroplasty: A Prospective Randomized Controlled Trial
Zheng C, Ma J, Xu J, Si H, Liu Y, Li M, Shen B
Orthopaedic surgery. 2022
OBJECTIVE There were limited randomized controlled trials (RCTs) of epsilon-aminocaproic acid (EACA) versus tranexamic acid (TXA) in total knee arthroplasty (TKA). The aim of the study was to compare the efficacy and safety of TXA and EACA in the combination of intravenous (IV) and intra-articular (IA) administration on reducing blood loss in patients following primary TKA. METHODS From January 2020 to January 2021, a total of 181 patients undergoing a primary unilateral TKA were enrolled in this prospective randomized controlled trial. Patients in the TXA group (n = 90) received 20 mg/kg of intravenous TXA preoperatively, 1 g of intra-articular TXA intraoperatively, and three doses of 20 mg/kg intravenous TXA at 0, 3, 6 h postoperatively. Patients in the EACA group (n = 91) received 120 mg/kg of intravenous EACA preoperatively, 2 g of intra-articular EACA intraoperatively, and three doses of 40 mg/kg intravenous EACA at 0, 3, 6 h postoperatively. The primary outcomes were total blood loss (TBL), transfusion rates and drop of hemoglobin (HB) level. The secondary outcomes included postoperative hospital stays and postoperative complications. The chi-square tests and Fisher's exact tests were utilized to compare categorical variables, while the independent-samples t-tests and Mann-Whitney tests were used to compare continuous variables. RESULTS The patients who received TXA averaged less TBL than the patients who received EACA (831.83 ml vs 1065.49 ml, P = 0.015), and HB drop in TXA group was generally less than that of EACA group on postoperative day 1 and 3 (20.84 ± 9.48 g/L vs 24.99 ± 9.40 g/L, P = 0.004; 31.28 ± 11.19 vs 35.46 ± 12.26 g/L, P = 0.047). The length of postoperative stays in EACA group was 3.66 ± 0.81 day, which is longer than 2.62 ± 0.68 day in TXA group (P < 0.001). No transfusions were required in either group. The risk of nausea and vomiting in TXA group was significantly higher than that in EACA group (11/90 vs 0/91, P < 0.01). CONCLUSION Although the TBL and HB drop were slightly greater in EACA group, these results were not clinically important, given that no transfusions were required. EACA could be an alternative to TXA, especially for patients with severe nausea and vomiting after using TXA postoperatively. Further studies are needed to adjust dosage of EACA to make better comparison of the two drugs.