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Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 20, Issue 12, pp 2494–2501 | Cite as

Efficacy of intra-articular tranexamic acid in blood loss reduction following primary unilateral total knee arthroplasty

  • Shuvendu Prosad RoyEmail author
  • Umair Firdos Tanki
  • Amitabh Dutta
  • Sumit Kumar Jain
  • Onkar Nath Nagi
Knee

Abstract

Purpose

The surgical stress of total knee arthroplasty (TKA) procedure and the application of intra-operative pneumatic thigh tourniquet increases local fibrinolytic activity, which contributes significantly to post-operative blood loss. Tranexamic acid, an antifibrinolytic drug, is commonly used to control post-operative blood loss. The recommended mode of administration of tranexamic acid is either oral or intravenous. However, the mechanism of action of the tranexamic acid points towards the possible effectiveness it may have following local/intra-articular application. This prospective, double-blinded, randomized preliminary study evaluated the efficacy of intra-articular tranexamic acid in reducing TKA-associated post-operative blood loss.

Methods

Fifty consenting patients with osteoarthritis of the knee scheduled for primary unilateral cemented-TKA were randomly allocated to one of the two groups: Tranexamic Acid (TA) group (n = 25, 500 mg/5 ml tranexamic acid) and the control group (n = 25, 5 ml 0.9% saline). The drug and control solution were administered intra-articularly through the drain tube immediately after the wound closure. Parameters related to blood loss (drop in haemoglobin, haematocrit differential) and the drain output [volume (ml)] were compared between the two groups.

Results

On a comparative basis, TA-group obtained significant reduction in the drain output [95% CI: 360.41–539.59, p < 0.001] at 48 h post-operatively. Even though the control group received sixfold more blood transfusion than TA-group, it showed a greater drop in haemoglobin and haematocrit (p < 0.05).

Conclusions

Local application of tranexamic acid seems to be effective in reducing post-TKA blood loss as well as blood transfusion requirements.

Level of evidence

Therapeutic study, Level II.

Keywords

TKA Tranexamic acid Blood loss Blood transfusion 

Notes

Acknowledgements

We thank Ms. Parul Takkar Chugh, statistician, for statistical analysis of data and its interpretation.

Conflict of interest

There is no potential conflict of interest of any of the authors in relation to this manuscript.

Ethical standard

The study was conducted after Institutional Ethics Committee approval.

References

  1. 1.
    Abul–Azm A, Abdullah KM (2006) Effect of topical tranexamic acid in open heart surgery. Eur J Anaesthesiol 23:380–384PubMedCrossRefGoogle Scholar
  2. 2.
    Astedt B, Liedholm P, Wingerup L (1978) The effect of tranexamic acid on the fibrinolytic activity of vein walls. Ann Chir Gynaecol 67:203–205PubMedGoogle Scholar
  3. 3.
    Benoni G, Carlsson A, Petersson C, Fredin H (1995) Does tranexamic acid reduce blood loss in knee arthroplasty? Am J Knee Surg 8:88–92PubMedGoogle Scholar
  4. 4.
    Benoni G, Fredin H (1996) Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after total knee arthroplasty; a prospective, randomized, double-blinded study of 86 patients. J Bone Joint Surg [Br] 78:434–440Google Scholar
  5. 5.
    Benoni G, Lethagen S, Fredin H (1997) The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res 85:195–206PubMedCrossRefGoogle Scholar
  6. 6.
    Carlin G, Karlstrom G, Modig J, Saldeen T (1980) Effect of dextran on fibrinolysis inhibition activity in the blood after major surgery. Acta Anaesthesiol Scand 24:375–378PubMedCrossRefGoogle Scholar
  7. 7.
    Cid J, Lozano M (2005) Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion 45:1302–1307PubMedCrossRefGoogle Scholar
  8. 8.
    Cushner FD, Friedman RJ (1991) Blood loss in total knee arthroplasty. Clin Ortho Rel Res 269:98–101Google Scholar
  9. 9.
    Dollery C (1991) Therapeutic drugs, 1st edn. Churchill Livingstone, LondonGoogle Scholar
  10. 10.
    Dunn CJ, Goa KL (1999) Tranexamic acid a review of its use in surgery and other indications. Drugs 57:1005–1032PubMedCrossRefGoogle Scholar
  11. 11.
    Good L, Peterson E, Lisander B (2003) Tranexamic acid decreases external blood loss but not hidden loss in total knee arthroplasty. Br J Anaesth 90:596–599PubMedCrossRefGoogle Scholar
  12. 12.
    Hiippala S, Strid L, Wennerstrand M, Arvela V, Mantlya S, Ylinen J, Niemela H (1995) Tranexamic acid (Cyclokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth 74:534–537PubMedCrossRefGoogle Scholar
  13. 13.
    Hiippala ST, Strid LJ, Wennerstrand MI, Arvela JVV, Niemela HM, Mantyla SK, Kuisma RP, Ylinen JE (1997) Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg 84:839–844PubMedGoogle Scholar
  14. 14.
    Ho KM, Ismail H (2003) Use of intravenous tranexemic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta analysis. Anaesth Intensive Care 31:529–537PubMedGoogle Scholar
  15. 15.
    Jansen AJ, Andreica S, Claeys M, D’Haese J, Camu F, Jochmans K (1999) Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty. Br J Anaesth 83:596–601PubMedCrossRefGoogle Scholar
  16. 16.
    Kaller H (1967) Enterale resorption, verteilung und elimination von 4-amino-methylcyclo-hexancarbonsaure (AMCHA) und ε-amino-capronsaure (ACS) beim menschen. Naunyn Schmiedebergs Arch Pharmak u exp Path 256:160–168CrossRefGoogle Scholar
  17. 17.
    Kambayashi J, Sakon M, Yokota M, Shiba E, Kawasaki T, Mori T (1990) Activation of coagulation and fibrinolysis during surgery, analyzed by molecular markers. Throm Res 60:157–167CrossRefGoogle Scholar
  18. 18.
    Kearon C, Julian JA, Math M, Newman TE, Ginsberg JS (1998) Noninvasive diagnosis of deep venous thrombosis. Ann Intern Med 128:663–667PubMedGoogle Scholar
  19. 19.
    Krohn CD, Sørensen R, Lange JE, Riise R, Bjørnsen S, Brosstad F (2003) Tranexamic acid given into the wound reduces postoperative blood loss by half in major orthopaedic surgery. Eur J Surg Suppl 588:57–61PubMedGoogle Scholar
  20. 20.
    Kruithof EKO, Nicolosa G, Bachmann F (1987) Plasminogen activator inhibitor 1: development of a radioimmunoassay and observations on its plasma concentration during venous occlusion and after platelet aggregation. Blood 70:1645–1653PubMedGoogle Scholar
  21. 21.
    Landers DF, Hill GE, Wong KC, Fox IJ (1996) Blood transfusion-induced immunomodulation. Anesth Analg 82:187–204PubMedGoogle Scholar
  22. 22.
    Langford RM, Mythen MC (2000) Critical care; fluid, electrolyte and acid-base balance; blood transfusion. In: Russel RCG, Williams NS, Bulstrode CJK (eds) Bailey and love’s short practice of surgery, 23rd edn. Edwar Arnold Ltd, London, pp 40–67Google Scholar
  23. 23.
    Longstaff C (1994) Studies on the mechanism of action of aprotinin and tranexamic acid as plasmin inhibitors and antifibrinolytic agents. Blood Coag Fibrinol 5:537–542Google Scholar
  24. 24.
    Murphy WG, Davies MJ, Eduardo A (1993) The haemostatic response to surgery and trauma. Br J Anaesth 70:205–213PubMedCrossRefGoogle Scholar
  25. 25.
    Nadler SB, Hidalgo JU, Bloch T (1962) Prediction of blood volume in normal human adults. Surgery 51:224–232PubMedGoogle Scholar
  26. 26.
    Nielsen HJ (1995) Detrimental effects of perioperative blood transfusion. Br J Surg 82:582–587PubMedCrossRefGoogle Scholar
  27. 27.
    American society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies (2006) Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 105:198–208Google Scholar
  28. 28.
    Petaja J, Myllye P, Myllynen P, Myllyla G, Vahtera E (1987) Fibrinolysis after application of pneumatic tourniquet. Acta Chir Scand 153:647–651PubMedGoogle Scholar
  29. 29.
    Sasanuma H, Sekiya H, Takatoku K, Takada H, Sugimoto N, Hoshino Y (2011) Efficient strategy for controlling postoperative hemorrhage in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 19:921–925PubMedCrossRefGoogle Scholar
  30. 30.
    Sehat KR, Evans RL, Newman JH (2004) Hidden blood loss following hip and knee arthroplasty correct management of blood loss should take hidden loss into account. J Bone Joint Surg 86:561–565Google Scholar
  31. 31.
    Sharrock NE, Go G, Williams-Russo P, Haas SB, Harpel PC (1997) Comparison of extra dural and general anaesthesia on the fibrinolytic response to total knee arthroplasty. Br J Anaesth [Br] 79:29–34CrossRefGoogle Scholar
  32. 32.
    Stringer MD, Steadman CA, Hedges AR, Thomas EM, Morley TR, Kakkar VV (1989) Deep vein thrombosis after elective knee surgery: an incidence study in 312 patients. J bone Joint Surg [Br] 71:492–497Google Scholar
  33. 33.
    Veien M, Sorensen JV, Madsen F, Juelsgaard P (2002) Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized, controlled study. Acta Anaesthesiol Scand 46:1206–1211PubMedCrossRefGoogle Scholar
  34. 34.
    Verstraete M (1985) Clinical application of inhibitors of fibrinolysis. Drugs 29:236–261PubMedCrossRefGoogle Scholar
  35. 35.
    Wong J, Abrishami A, Beheiry HE, Mahomed NN, Davey JR, Gandhi R, Syed KA, Hasan SMO, Silva DY, Chung F (2010) Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg [Am] 92:2503–2513CrossRefGoogle Scholar
  36. 36.
    Zhang H, Chen J, Chen F, Que W (2011) The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-011-1754-z

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Shuvendu Prosad Roy
    • 1
    Email author
  • Umair Firdos Tanki
    • 2
  • Amitabh Dutta
    • 3
  • Sumit Kumar Jain
    • 1
  • Onkar Nath Nagi
    • 1
  1. 1.Joint Replacement and Reconstruction UnitSir Ganga Ram HospitalNew DelhiIndia
  2. 2.Department of OrthopaedicSir Ganga Ram HospitalNew DelhiIndia
  3. 3.Department of Anaesthesiology, Pain and Perioperative-MedicineSir Ganga Ram HospitalNew DelhiIndia

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