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A randomised non-inferiority trial comparing the effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty
DeFrancesco CJ, Reichel JF, Gbaje E, Popovic M, Freeman C, Wong M, DeMeo D, Liu J, Gonzalez Della Valle A, Ranawat A, et al
British journal of anaesthesia. 2022
Abstract
BACKGROUND Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective. METHODS This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery. RESULTS Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00). CONCLUSIONS Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.
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Preemptive antifibrinolysis: its role and efficacy in hip-fracture patients undergoing total hip arthroplasty
Liu J, Lei Y, Liao J, Liang X, Hu N, Huang W
The Journal of arthroplasty. 2021
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Editor's Choice
Abstract
BACKGROUND We aimed to determine the efficacy of preemptive antifibrinolysis with tranexamic acid (TXA) in decreasing hidden blood loss (HBL) in the elderly hip fracture patients. METHODS 96 elderly hip fracture patients receiving hip arthroplasty were randomized to receive 100 ml of normal-saline (Group A) or 1.5 g of TXA (Group B) intravenously q12h from post-admission day 1 (PAD1) to the day before surgery. Both groups were treated with 1.5 g of TXA q12h from postoperative day 1 (POD1) to POD3. HBL was calculated by formulas and recorded as the primary outcome. RESULTS In overall analyses, no difference was found in HBL, while the decline-of-hemoglobin (ΔHb), allogeneic-blood-transfusion (ABT) rate, fibrinogen-degradation-product (FDP, on PAD2, PAD3, POD1 and POD2) and D-dimer (D-D, on PAD2, PAD3 and POD1) were lower in Group B. In subgroup analyses for patients receiving intervention within 72 hours of injury, Group B had lower postoperative HBL, ΔHb, ABT rate, FDP and D-D levels (on PAD2, PAD3, POD1 and POD2). For patients receiving intervention over 72 hours after injury, no difference was detected in perioperative HBL, ΔHb, ABT rate between the two groups. The FDP and D-D levels were lower in Group B on PAD2 and PAD3. No difference was found in coagulation parameters, wound complications, VTE rate and 90-day mortality in all analyses. CONCLUSION Early administration (within 72 hours of injury) of multi-dose of TXA is effective in reducing perioperative HBL in elderly hip fracture patients. Delayed use (over 72 hours after injury) of TXA was not beneficial.
PICO Summary
Population
Elderly hip fracture patients undergoing total hip arthroplasty (n= 96).
Intervention
Intravenous tranexamic acid (TXA) every 12 hours from post-admission day to the day before surgery (n= 48).
Comparison
Normal saline (n= 48).
Outcome
No difference was found in hidden blood loss, while the decline-of-haemoglobin (ΔHb), allogeneic-blood-transfusion (ABT) rate, fibrinogen-degradation-product and D-dimer were lower in patients receiving TXA. For patients receiving intervention over 72 hours after injury, no difference was detected in perioperative hidden blood loss, ΔHb, ABT rate between the two groups. No difference was found in coagulation parameters, wound complications, venous thromboembolism rate and 90-day mortality.
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The clinical efficacy of leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials
Zhao D, Han YH, Pan JK, Yang WY, Zeng LF, Liang GH, Liu J
Journal of shoulder and elbow surgery. 2020
Abstract
BACKGROUND The efficacy of platelet-rich plasma (PRP) in the arthroscopic treatment of rotator cuff injury has been reported in the literature. However, conclusions have been inconsistent and more often related to differences in the types of PRP used. Therefore, to minimize these differences, we performed a meta-analysis of only studies investigating leukocyte-poor PRP to evaluate whether PRP promotes and improves the effects of arthroscopic rotator cuff repair. METHODS A comprehensive search of the PubMed, Embase and Cochrane Library databases was conducted to evaluate the efficacy of leukocyte-poor PRP in arthroscopic rotator cuff repair. The available data were extracted, and the methodological quality of the included studies was evaluated by the Cochrane risk of bias assessment tool. RESULTS In total, 10 randomized controlled trials involving 742 patients were included. The results of the meta-analysis showed that treatment with leukocyte-poor PRP performed better in relieving postoperative pain than the control in the short-term [MD = -0.57, 95% CI (-0.79, -0.35), P < 0.0001] and long-term [MD = -0.18, 95% CI (-0.34, -0.03), P = 0.02]) follow-up. However, the changes in the mean VAS difference were below the MCID. Regarding the Constant shoulder [MD = 3.35, 95% CI (1.68, 5.02), P < 0.0001] and UCLA [MD = 1.73, 95% CI (0.94, 2.52), P < 0.0001] scores, there was a statistically significant difference in favor of leukocyte-poor PRP over the control. However, the changes in the mean difference of both the Constant and UCLA scores were below the MCID. Moreover, during the medium- and long-term follow-up, the retear rate in the leukocyte-poor PRP group was lower than that in the control group regardless of the rotator cuff tear size [small and medium (< 3 cm) ([RR = 0.64, 95% CI (0.43, 0.97), P = 0.03]) vs medium and large (> 3 cm) ([RR = 0.51, 95% CI (0.34, 0.77), P = 0.001])] and surgical repair methods (single-row repair ([RR = 0.61, 95% CI (0.43, 0.87), P = 0.007]) vs double-row suture bridge repair ([RR = 0.57, 95% CI (0.38, 0.84), P = 0.005])). CONCLUSION According to the current study, leukocyte-poor PRP can significantly reduce the postoperative retear rate in the medium and long term regardless of the tear size and methods used for rotator cuff repair. However, the use of leukocyte-poor PRP in terms of postoperative pain and patient reported outcomes failed to show clinically meaningful effects. LEVEL OF EVIDENCE Level II; Systematic Review/Meta-Analysis.
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Tranexamic acid is beneficial for blood management of high tibial osteotomy: a randomized controlled study
Ni J, Liu J, Zhang J, Jiang J, Dang X, Shi Z
Arch Orthop Trauma Surg. 2020
Abstract
INTRODUCTION The purpose of this study was to investigate whether TXA can effectively reduce blood loss after HTO and related complications and to evaluate its safety. MATERIALS AND METHODS From March 2016 to March 2018, 100 patients who underwent medial opening wedge HTO in the Department of Orthopedics, the second affiliated hospital of xi'an jiaotong university, with an average age of 52.8 ± 3.2 years, were randomly divided into the TXA group (using intravenous TXA) and the control group (using the same amount of normal saline), with 50 patients in each group. The postoperative wound drainage volume, decrease in hemoglobin and hematocrit value, total blood loss, wound healing, blood transfusion, deep venous thrombosis (DVT) and pulmonary embolism (PE) were compared between the two groups. RESULTS The drainage volume on the first postoperative day and the total drainage volume of the TXA group were significantly lower compared with those of the control group (145.7 vs 264.5 ml, 282.3 vs 413.2 ml, P < 0.05). The decreases in the hemoglobin and hematocrit values on the postoperative first, second and fifth days were lower in the TXA group than those in the control group (1.4 VS 3.5, 2.6 vs 3.3, 1.9 vs 2.9 g, P < 0.05; 3.3 vs 5.5, 5.0 vs 9.1, 3.8 vs 7.2%, P < 0.05), and the mean total blood loss was also lower in the TXA group than that in the control group (477.9 vs 834.6 ml, P < 0.05). In the control group, 1 patient had wound hematoma requiring additional paracentesis and pressure dressing, 1 patient had superficial wound infection requiring additional debridement, and 1 patient had postoperative blood transfusion compared to none in the TXA group (P > 0.05). There was no symptomatic DVT or PE in either of the groups. CONCLUSION Intravenous TXA can effectively and safely reduce blood loss and bleeding-related complications after HTO and was beneficial for the blood management of HTO.
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Comparison between oral and intravenous application of tranexamic acid for total hip arthroplasty: a meta-analysis
Wang L, Cao JG, Liu J
Journal of comparative effectiveness research. 2019
Abstract
AIM: We conducted a meta-analysis to compare the efficacy and safety of oral and intravenous applications of tranexamic acid (TXA) in total hip arthroplasty (THA). MATERIALS & METHODS Electronic databases, including PubMed, Cochrane CENTRAL, ScienceDirect and Embase, were searched to identify the studies comparing the efficacy and safety of oral and intravenous applications of TXA in THA. Relevant journals and conference proceedings were manually searched. The pooled data were analyzed using RevMan 5.1. RESULTS Four randomized control trials and one retrospective study were identified. A meta-analysis showed no significant differences in hemoglobin reduction, total blood loss and transfusion requirements. CONCLUSION Oral applications of TXA are comparable to intravenous applications of TXA in primary unilateral THA for blood conservation and cost-saving measures.
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Is the combined application of both drain-clamping and tranexamic acid superior to the single use of either application in patients with total-knee arthroplasty?: A meta-analysis of randomized controlled trials
Han YH, Huang HT, Pan JK, Zeng LF, Liang GH, Liang HD, Yang WY, Guo D, Liu J
Medicine. 2018;97((36)):e11573.
Abstract
BACKGROUND To compare the efficacy and safety of the combined application of both drain-clamping and tranexamic acid (TXA) versus the single use of either application in patients with total-knee arthroplasty (TKA). METHODS Databases (EMBASE, PubMed, Cochrane Library, Web of Sciences, the Google database, and the Ovid database) were searched from their inception through April 2018 for randomized controlled trials (RCTs) comparing the combined application of both drain-clamping and TXA versus single use of either application in patients with TKA. The Cochrane risk of bias (ROB) tool was used to assess the methodologic quality. The primary outcomes were blood loss in drainage, total blood loss, transfusion rate, and hemoglobin decline. The secondary outcomes were postoperative complications, the Knee Society Score (KSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The statistical analysis was performed with RevMan 5.3.5 software. RESULTS A total of five RCTs (479 participants) were included in our meta-analysis. The present meta-analysis indicated that significant differences existed in the total blood loss (mean difference [MD] = -145.86, 95% confidence interval [CI]: -228.64 to -63.08, P = .0006), blood loss in drainage (MD = -169.06, 95% CI: -248.56 to -89.57, P < .0001), hemoglobin decline (MD = -0.66, 95% CI: -1.00 to -0.33, P = .0001), and transfusion rate (MD = 0.44, 95% CI: 0.26-0.75, P = .002) between the groups. However, regarding postoperative complications, no significant differences were found between the 2 groups in the KSS and the WOMAC score (P > .05). CONCLUSION Combined application of both drain-clamping and TXA was associated with significant reductions in blood loss in drainage, total blood loss, hemoglobin decline, and the need for transfusion. However, high-quality, well-designed RCTs with long-term follow-up are still required.
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Review: Autologous blood transfusion drainage compared with no drainage in total knee arthroplasty: a meta-analysis and systematic review
Hong KH, Pan JK, Xie H, Guo D, Yang WY, Su HT, Xu SC, Liu J
Pakistan Journal of Pharmaceutical Sciences.. 2017;30((6)):2321-2327.
Abstract
This is the first meta-analysis to assess the clinical efficiency, safety and potential advantages regarding the use of ABT drains compared with no drainage which is controversial in total knee arthroplasty (TKA).A comprehensive literature search was carried out in March 2015 using the PubMed, Embase, and Cochrane Library databases. A metaanalysis was carried out on two retrospective comparative studies (RCSs) and five randomized controlled trials (RCTs). The number of patients receiving homologous blood transfusion was the primary outcome of the meta-analysis; the secondary outcome measure was the mean drop in Hb level in comparison to the mean pre-operative HB level, the range of flexion of the knee joint, and infections of the wound after surgery. A total of 868 patients, who were included in two retrospective studies and five RCTs, were distributed into subgroups for the meta-analysis. This pooled data showed no benefit of ABT drainage compared no drainage in the homologous blood transfusion rate (13.05% and 16.91%, OR:0.73[0.47,1.13], Z=1.41, P=0.016; and 3.49% and 6.54%, OR: 0.50[0.12,2.01], Z=0.98,P=0.033,respectively in subgroups), Hb drop (Weight mean differences (WMD): 0.20[-0.28,0.68], Z=0.82, P=0.41; WMD:0.16[-0.41,0.55], Z=0.93, P=0.35, respectively), range of flexion of the knee joint (WMD:-0.82 [-3.35,1.70], Z =0.64,P=0.52)and wound infection (OR:0.25[0.61,10.20]; Z =1.28, p=0.2) after TKA surgery. Our findings do not recommend the routine use of postoperative ABT drainage in total knee arthroplasty. Well-designed RCTs with large sample sizes, longer term measures and extensive follow-up period should be performed in the future to update the findings of this study.
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Tranexamic acid decreases visible and hidden blood loss without affecting prethrombotic state molecular markers in transforaminal thoracic interbody fusion for treatment of thoracolumbar fracture-dislocation
Wang W, Duan K, Ma M, Jiang Y, Liu T, Liu J, Hao D
Spine. 2017;43((13):):E734-E739
Abstract
STUDY DESIGN A randomized, double-blind, placebo-controlled clinical trial OBJECTIVE.: To evaluate the efficacy and safety of tranexamic acid (TXA) administered during the surgical correction of thoracolumbar fracture-dislocation SUMMARY OF BACKGROUND DATA.: Thoracolumbar fracture-dislocation surgery is generally associated with substantial blood loss and a high risk of deep vein thrombosis (DVT). TXA has been shown to improve hemostasis in surgical procedures. METHODS We investigated 80 patients with thoracolumbar fracture-dislocation who underwent transforaminal thoracic interbody fusion (TTIF) between March 2014 and December 2016. The patients were randomized into the TXA (n = 39) and Placebo (n = 41) groups, according to whether they did or did not receive pre- and intraoperative TXA treatment. The two groups were compared for demographic characteristics as well as pre- and postoperative levels of prethrombosis-state molecular markers and visible and hidden blood loss volumes. Additionally, the prevalence of TXA-related complications was determined. RESULTS The two groups did not differ significantly in demographic characteristics. The visible blood loss (intra- and postoperative bleeding during the first 24 h), hidden blood loss, and true total blood loss during surgery in the TXA group were significantly lower than those in the Placebo group (835 +/- 180.3 mL, 351 +/- 82.3 mL, 1385 +/- 102.3 mL vs. 1155 +/- 175.3 mL, 564 +/- 170.5 mL, 1683 +/- 121.0 mL, respectively; P < 0.01). Furthermore, the levels of the prethrombosis-state molecular markers GMP-140, FIB, FDP, and D-dimer were higher in the TXA group than in the Placebo group, although the differences were not significant (P > 0.05). No significant intergroup differences were noted in the prevalence of deep venous thrombosis and pulmonary embolus during the study period. CONCLUSION TXA significantly reduced visible and hidden blood loss without affecting the prethrombosis-state molecular markers in TTIF or causing any notable adverse effects. LEVEL OF EVIDENCE 3.
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A comparison of combined intravenous and topical administration of tranexamic acid with intravenous tranexamic acid alone for blood loss reduction after total hip arthroplasty: a meta-analysis
Liu X, Liu J, Sun G
International Journal of Surgery (London, England). 2017;41:34-43
Abstract
BACKGROUND The optimal dose and protocol of tranexamic acid (TXA) for reducing blood loss in total hip arthroplasty (THA) is controversial. Intravenous TXA (IV-TXA) and combined IV-TXA with topical TXA are the two common protocol after THA. A meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of combined IV and topical TXA with IV-TXA alone in reducing blood loss after THA. METHODS PubMed, Medline, Embase, Web of Science, the Cochrane Library, China Wanfang database and Google database were searched from the inception to February 2017 to identify RCTs that comparing combined IV and topical TXA with IV-TXA alone for patients prepared for primary THA. Total blood loss, hidden blood loss, transfusion rate, hemoglobin drop, length of hospital stay and the occurrence of deep venous thrombosis (DVT) were pooled to comprehensive analyses the efficacy and safety of combined IV and topical TXA with IV-TXA alone. Software Stata 12.0 was used to calculated relevant data. RESULTS Six RCTs involving 747 patients were finally included in the meta-analysis. Combined TXA decrease the volume of total blood loss and hidden blood loss by 250.37 ml (MD = -250.37; 95% CI: -376.43 to -124.31, P = 0.000) and 117.23 ml respectively (MD = -117.23; 95% CI: 228.38 to -6.07, P = 0.091). Meanwhile, combined TXA can also decrease the transfusion rate by 9.1% (RR = 0.32; 95% CI: 0.17 to 0.63; P = 0.001). No significant differences were seen in hemoglobin drop, the length of hospital stay and the occurrence of DVT between the two groups (P > 0.05). CONCLUSIONS Our meta-analysis suggests that the combined application of IV and topical TXA for patients undergoing THA may reduce the total blood loss compared with IV use alone without increasing the risk of postoperative complications. However, due to the quality and number of included studies, more studies were need to further identify the optimal dose for combine IV-TXA.
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Intra-articular versus intravenous tranexamic acid application in total knee arthroplasty: a meta-analysis of randomized controlled trials
Mi B, Liu G, Zhou W, Lv H, Liu Y, Zha K, Wu Q, Liu J
Archives of Orthopaedic and Trauma Surgery. 2017;137((7):):997-1009
Abstract
BACKGROUND The purpose of this meta-analysis was to compare the blood loss and complications of intra-articular (IA) with intravenous (IV) tranexamic acid (TXA) for total knee arthroplasty (TKA). METHODS A comprehensive search of studies was conducted to identify related articles in Pubmed, Embase, Cochrane central Register of Controlled Trials, springerLink, OVID and the Research published from January 1980 to September 2016. All studies that compared IA TXA with IV TXA application on TKA were included. Main outcomes of the two methods were collected and analyzed by using Review Manager 5.3. RESULTS There were 16 randomized controlled trials with 1308 cases met the criteria. Compared with IV TXA, IA TXA had similar blood volume of drainage, hidden blood loss, transfusion rate and complications (P > 0.05). IA TXA had lower total blood loss than IV TXA, and there was significant difference (P < 0.05). Subgroup analysis of total blood loss based on times of IV TXA administration showed that repeat dose of IV TXA had a higher total blood loss and postoperative hemoglobin drop (P < 0.05) than IA TXA. However, single dose of IV TXA had a similar efficacy on total blood loss and postoperative hemoglobin drop (P > 0.05) when compared with IA TXA. CONCLUSIONS Both IA TXA and single dose of IV TXA are effective in reducing total blood loss and postoperative hemoglobin drop without increasing complications of DVT or PE. The current meta-analysis suggests that 1.5 g TXA by IA administration or 1 g TXA by IV administration 10 min before tourniquet deflation is effective and safe in patients undergoing TKA.