Comparison of combined intravenous and topical use of tranexamic acid with different dosage in primary total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WU Jun ¹ , LI Guangyi ² ^△ , CHEN Yunsu ² , DENG Jianhua ¹ ,  ZHANG Changqing ²

1. Department of Orthopaedics, Nantong Sixth People’s Hospital, Nantong Jiangsu, 226011, P.R.China;
2. Department of Orthopaedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiaotong University, Shanghai, 200233, P.R.China;

Corresponding?author：

ZHANG Changqing, Email: zhangchq62@126.com

Keywords：

Tranexamic acid; total knee arthroplasty; intra-articular injection; postoperative blood loss

DOI：

10.7507/1002-1892.201805008

Video：

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Objective To compare the efficacy and safety of intra-articular combined with intravenous administration of tranexamic acid (TXA) with different dosage for reducing blood loss in primary total knee arthroplasty (TKA). Methods Between January 2017 and June 2017, 90 patients suffering from unilateral osteoarthritis who underwent primary TKA were randomly scheduled to three interventions, named groups A, B, and C. Single dosage of TXA via intravenous injection (IV) and different dosages of TXA via intra-articular injection (IA) were utilized in three groups, respectively. All patients in three groups received 1 g TXA IV at 10 minutes preoperatively, and received 1, 2, and 3 g TXA IA diluted in 50 mL saline after wound closure in groups A, B and C, respectively. The age, gender, body mass index, affected side of the knee, grade of osteoarthritis, grade of America Society of Anesthesiologist, preoperative hemoglobin (Hb) concentration, platelet count, preoperative prothrombin time, and activated partial thromboplastin time were not significantly different between groups (P>0.05). The postoperative wound blood drainage, Hb concentration at 1, 3, and 7 days after operation, transfusion rate, and thromboembolic complications were observed. All patients were routinely observed for deep vein thrombosis (DVT) by the color Doppler ultrasonography at 1 week, 1 month, and 3 months after operation, and the symptomatic pulmonary embolism (PE) were observed. Results All patients in three groups were followed up 7-12 months (mean, 8.4 months). There was no significant difference in operation time between groups (P>0.05). The postoperative wound blood drainage was significantly less in groups B and C than that in group A (P<0.05), whereas no significant difference was found between group B and group C (P>0.05). Incision skin necrosis occurred in 1 case of group B and fat liquefaction occurred in 1 case of group C. The other incisions of 3 groups healed by first intention. There was no significant difference in incision complication incidence between groups. The Hb concentration was significantly higher in groups B and C than that in group A at 1, 3, and 7 days after operation (P<0.05). While between group B and group C, the significant difference of Hb concentration only existed at 1 day after operation (P<0.05). The number of patients who got blood transfusion was significantly less in group B (4 cases, 13.3%) and group C (5 cases, 16.7%) than that in group A (9 cases, 30%) (P< 0.05), but no significant difference was found between group B and group C (P>0.05). The result of color Doppler ultrasonography showed that 1 case got DVT in the contralateral calf at 3 weeks in group B. And there was no symptomatic PE in 3 groups. Conclusion Combined administration of IV and IA TXA in a clinically relevant reduction in blood loss was effective and safe in primary TKA, and no thromboembolic complication was observed. The combination of 1 g IV with 2 g IA could be the optional choice.

Citation： WU Jun, LI Guangyi, CHEN Yunsu, DENG Jianhua, ZHANG Changqing. Comparison of combined intravenous and topical use of tranexamic acid with different dosage in primary total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(11): 1397-1401. doi: 10.7507/1002-1892.201805008 Copy

1.	Wong J, Abrishami A, EI Beheiry H, 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(15): 2503-2513.
2.	Nielsen CS, Jans ?, ?rsnes T, et al. Combined intra-articular and intravenous tranexamic acid reduces blood loss in total knee arthroplasty: A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg (Am), 2016, 98(10): 835-841.
3.	Yuan X, Li B, Wang Q, et al. Comparison of 3 routes of administration of tranexamic acid on primary unilateral total knee arthroplasty: A prospective, randomized, controlled study. J Arthroplasty, 2017, 32(9): 2738-2743.
4.	Hoylaerts M, Lijnen HR, Collen D. Studies on the mechanism of the antifibrinolytic action of tranexamic acid. Biochim Biophys Acta, 1981, 673(1): 75-85.
5.	Boese CK, Centeno L, Walters RW. Blood conservation using tranexamic acid is not superior to epsilon-aminocaproic acid after total knee arthroplasty. J Bone Joint Surg (Am), 2017, 99(19): 1621-1628.
6.	Stowers MDJ, Aoina J, Vane A, et al. Tranexamic acid in knee surgery study-A multicentered, randomized, controlled trial. J Arthroplasty, 2017, 32(11): 3379-3384.
7.	李銳博, 尹詩九, 鐘航, 等. 靜脈聯合關節腔內注射氨甲環酸后引流管夾閉時間對人工全膝關節置換術后失血量的影響及安全性評價. 中國修復重建外科雜志, 2017, 31(4): 417-421.
8.	Franchini M, Mengoli C, Marietta M, et al. Safety of intravenous tranexamic acid in patients undergoing majororthopaedic surgery: a meta-analysis of randomised controlled trials. Blood Transfus, 2018, 16(1): 36-43.
9.	Liu X, Liu J, Sun G. 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. Int J Surg, 2017, 41: 34-43.
10.	Zhang P, Li JF, Wang X. Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials. Int J Surg, 2017, 43: 171-180.
11.	Xie J, Ma J, Yue C, et al. Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial. Hip Int, 2016, 26(1): 36-42.
12.	Lin SY, Chen CH, Fu YC, et al. The efficacy of combined use of intraarticular and intravenous tranexamic acid on reducing blood loss and transfusion rate in total knee arthroplasty. J Arthroplasty, 2015, 30(5): 776-780.
13.	Kim YH, Pandey K, Park JW, et al. Comparative efficacy of intravenous with intra-articular versus intravenous only administration of tranexamic acid to reduce blood loss in knee arthroplasty. Orthopedics, 2018, 17: 1-4.
14.	Xiong H, Liu Y, Zeng Y, et al. The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord, 2018, 19(1): 321.
15.	Fillingham YA, Ramkumar DB, Jevsevar DS, et al. The efficacy of tranexamic acid in total hip arthroplasty: A network meta-analysis. J Arthroplasty, 2018, 33(10): 3083-3089.
16.	周宗科, 翁習生, 曲鐵兵, 等. 中國髖、膝關節置換術加速康復——圍術期管理策略專家共識. 中華骨與關節外科雜志, 2016, 9(1): 1-9.
17.	中華醫學會骨科學分會. 預防骨科大手術深靜脈血栓形成指南(草案). 中國矯形外科雜志, 2009, 17(2): 118-119.
18.	岳辰, 周宗科, 裴福興, 等. 中國髖、膝關節置換術圍術期抗纖溶藥序貫抗凝血藥應用方案的專家共識. 中華骨與關節外科雜志, 2015, 8(4): 281-285.
19.	李林濤, 吳海山, 吳宇黎, 等. 人工關節置換術圍手術期的血液管理策略. 中國修復重建外科雜志, 2015, 29(6): 772-776.
20.	White CC 4th, Eichinger JK, Friedman RJ. Minimizing blood loss and transfusions in total knee arthroplasty. J Knee Surg, 2018, 31(7): 594-599.
21.	Fransen BL, Hoozemans MJM, Argelo KDS, et al. Fast-track total knee arthroplasty improved clinical and functional outcome in the first 7 days after surgery: a randomized controlled pilot study with 5-year follow-up. Arch Orthop Trauma Surg, 2018, 138(9): 1305-1316.
22.	Huang Z, Xie X, Li L, et al. Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary total knee arthroplasty: A prospective, randomized controlled trial. J Bone Joint Surg (Am), 2017, 99(24): 2053-2061.
23.	Emara WM, Moez KK, Elkhouly AH. Topical versus intravenous tranexamic acid as a blood conservation intervention for reduction of post-operative bleeding in hemiarthroplasty. Anesth Essays Res, 2014, 8(1): 48-53.
24.	Fillingham YA, Ramkumar DB, Jevsevar DS, et al. The safety of tranexamic acid in total joint arthroplasty: A direct meta-analysis. J Arthroplasty, 2018, 33(10): 3070-3082.
25.	Kim YT, Kang MW, Lee JK, et al. 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. BMC Musculoskelet Disord, 2018, 19(1): 227.
26.	Jansen JA, Lameijer JRC, Snoeker BAM. Combined intravenous, topical and oral tranexamic acid administration in total knee replacement: Evaluation of safety in patients with previous thromboembolism and effect on hemoglobin level and transfusion rate. Knee, 2017, 24(5): 1206-1212.
27.	Heller S, Secrist E, Shahi A, et al. Tranexamic acid can be administered to arthroplasty patients who receive aspirin for venous thromboembolic prophylaxis. J Arthroplasty, 2016, 31(7): 1437-1441.

1. Wong J, Abrishami A, EI Beheiry H, 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(15): 2503-2513.
2. Nielsen CS, Jans ?, ?rsnes T, et al. Combined intra-articular and intravenous tranexamic acid reduces blood loss in total knee arthroplasty: A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg (Am), 2016, 98(10): 835-841.
3. Yuan X, Li B, Wang Q, et al. Comparison of 3 routes of administration of tranexamic acid on primary unilateral total knee arthroplasty: A prospective, randomized, controlled study. J Arthroplasty, 2017, 32(9): 2738-2743.
4. Hoylaerts M, Lijnen HR, Collen D. Studies on the mechanism of the antifibrinolytic action of tranexamic acid. Biochim Biophys Acta, 1981, 673(1): 75-85.
5. Boese CK, Centeno L, Walters RW. Blood conservation using tranexamic acid is not superior to epsilon-aminocaproic acid after total knee arthroplasty. J Bone Joint Surg (Am), 2017, 99(19): 1621-1628.
6. Stowers MDJ, Aoina J, Vane A, et al. Tranexamic acid in knee surgery study-A multicentered, randomized, controlled trial. J Arthroplasty, 2017, 32(11): 3379-3384.
7. 李銳博, 尹詩九, 鐘航, 等. 靜脈聯合關節腔內注射氨甲環酸后引流管夾閉時間對人工全膝關節置換術后失血量的影響及安全性評價. 中國修復重建外科雜志, 2017, 31(4): 417-421.
8. Franchini M, Mengoli C, Marietta M, et al. Safety of intravenous tranexamic acid in patients undergoing majororthopaedic surgery: a meta-analysis of randomised controlled trials. Blood Transfus, 2018, 16(1): 36-43.
9. Liu X, Liu J, Sun G. 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. Int J Surg, 2017, 41: 34-43.
10. Zhang P, Li JF, Wang X. Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials. Int J Surg, 2017, 43: 171-180.
11. Xie J, Ma J, Yue C, et al. Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial. Hip Int, 2016, 26(1): 36-42.
12. Lin SY, Chen CH, Fu YC, et al. The efficacy of combined use of intraarticular and intravenous tranexamic acid on reducing blood loss and transfusion rate in total knee arthroplasty. J Arthroplasty, 2015, 30(5): 776-780.
13. Kim YH, Pandey K, Park JW, et al. Comparative efficacy of intravenous with intra-articular versus intravenous only administration of tranexamic acid to reduce blood loss in knee arthroplasty. Orthopedics, 2018, 17: 1-4.
14. Xiong H, Liu Y, Zeng Y, et al. The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord, 2018, 19(1): 321.
15. Fillingham YA, Ramkumar DB, Jevsevar DS, et al. The efficacy of tranexamic acid in total hip arthroplasty: A network meta-analysis. J Arthroplasty, 2018, 33(10): 3083-3089.
16. 周宗科, 翁習生, 曲鐵兵, 等. 中國髖、膝關節置換術加速康復——圍術期管理策略專家共識. 中華骨與關節外科雜志, 2016, 9(1): 1-9.
17. 中華醫學會骨科學分會. 預防骨科大手術深靜脈血栓形成指南(草案). 中國矯形外科雜志, 2009, 17(2): 118-119.
18. 岳辰, 周宗科, 裴福興, 等. 中國髖、膝關節置換術圍術期抗纖溶藥序貫抗凝血藥應用方案的專家共識. 中華骨與關節外科雜志, 2015, 8(4): 281-285.
19. 李林濤, 吳海山, 吳宇黎, 等. 人工關節置換術圍手術期的血液管理策略. 中國修復重建外科雜志, 2015, 29(6): 772-776.
20. White CC 4th, Eichinger JK, Friedman RJ. Minimizing blood loss and transfusions in total knee arthroplasty. J Knee Surg, 2018, 31(7): 594-599.
21. Fransen BL, Hoozemans MJM, Argelo KDS, et al. Fast-track total knee arthroplasty improved clinical and functional outcome in the first 7 days after surgery: a randomized controlled pilot study with 5-year follow-up. Arch Orthop Trauma Surg, 2018, 138(9): 1305-1316.
22. Huang Z, Xie X, Li L, et al. Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary total knee arthroplasty: A prospective, randomized controlled trial. J Bone Joint Surg (Am), 2017, 99(24): 2053-2061.
23. Emara WM, Moez KK, Elkhouly AH. Topical versus intravenous tranexamic acid as a blood conservation intervention for reduction of post-operative bleeding in hemiarthroplasty. Anesth Essays Res, 2014, 8(1): 48-53.
24. Fillingham YA, Ramkumar DB, Jevsevar DS, et al. The safety of tranexamic acid in total joint arthroplasty: A direct meta-analysis. J Arthroplasty, 2018, 33(10): 3070-3082.
25. Kim YT, Kang MW, Lee JK, et al. 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. BMC Musculoskelet Disord, 2018, 19(1): 227.
26. Jansen JA, Lameijer JRC, Snoeker BAM. Combined intravenous, topical and oral tranexamic acid administration in total knee replacement: Evaluation of safety in patients with previous thromboembolism and effect on hemoglobin level and transfusion rate. Knee, 2017, 24(5): 1206-1212.
27. Heller S, Secrist E, Shahi A, et al. Tranexamic acid can be administered to arthroplasty patients who receive aspirin for venous thromboembolic prophylaxis. J Arthroplasty, 2016, 31(7): 1437-1441.

Chinese Journal of Reparative and Reconstructive Surgery

Comparison of combined intravenous and topical use of tranexamic acid with different dosage in primary total knee arthroplasty

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