Skip to main content

Advertisement

Log in

Tranexamic Acid Reduces Blood Loss and Blood Transfusion after TKA: A Prospective Randomized Controlled Trial

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

TKA may be associated with considerable blood loss, and transfusion carries substantial risk of immunologic reaction and disease transmission. Blood transfusion also involves additional cost, therefore a reduction in its use is important. Several methods reportedly reduce postoperative blood loss and avoid homologous blood transfusion with traditional TKA approaches, but it is unclear these reductions apply to a minimally invasive technique.

Questions/purposes

We asked whether tranexamic acid administration could reduce blood loss and blood transfusion requirements after TKA.

Patients and Methods

Between March 2008 and May 2008, we enrolled 100 patients with primary osteoarthritis undergoing a unilateral cemented TKA in a prospective, randomized, double-blind study. Patients were randomized into one of two groups: the control group received a placebo and the study group received tranexamic acid intravenously (10 mg/kg) 10 minutes before inflation of the tourniquet and 3 hours postoperatively and orally (250 mg/capsule; two capsules three times daily) for 5 days. We measured volume of drained blood 48 hours postoperatively, decrease in hemoglobin levels 12 hours postoperatively, amount of blood transfused, and number of patients requiring allogenic blood transfusion. The minimum followup was 6 months (mean, 10.4 months; range, 6–12 months).

Results

Mean (± SD) postoperative volume of drained blood was lower in the group receiving tranexamic acid (727.50 ± 234 mL) than in control subjects (1208.77 ± 421 mL). The mean hemoglobin decrease 12 hours postoperatively was lower in patients receiving tranexamic acid (2.12 ± 0.64 g/dL) than in control subjects (3.33 ± 0.88 g/dL). The amount of blood transfused and number of patients requiring blood transfusion were lower in patients receiving tranexamic acid than in control subjects.

Conclusions

Tranexamic acid reduced postoperative blood loss after TKA, as reflected in reduction in the number of blood transfusions. We did not observe any change in symptomatic thromboembolic phenomenon.

Level of Evidence

Level 1, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Adalberth G, Bystrom S, Kolstad K, Mallmin H, Millbrink J. Postoperative drainage of knee arthroplasty is not necessary: a randomized study of 90 patients. Acta Orthop Scand. 1998;69:475–478.

    Article  PubMed  CAS  Google Scholar 

  2. Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M. Effect of tourniquet use on activation of coagulation in total knee arthroplasty. Clin Orthop Relat Res. 2000;371:169–177.

    Article  PubMed  Google Scholar 

  3. Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion. 2008;48:519–525.

    Article  PubMed  Google Scholar 

  4. Andersson L, Nilsson IM, Nilehn JE, Hedner U, Granstrand B, Melander B. Experimental and clinical studies on AMCA, the antifibrinolytically active isomer of p-aminomethyl cyclohexane carboxylic acid. Scand J Haematol. 1965;2:230–247.

    Article  PubMed  CAS  Google Scholar 

  5. Benoni G, Bjorkman S, Fredin H. Application of pharmacokinetic data from healthy volunteers for the prediction of plasma concentrations of tranexamic acid in surgical patients. Clin Drug Invest. 1995:10:280–287.

    Article  CAS  Google Scholar 

  6. Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients. J Bone Joint Surg Br. 1996;78:434–440.

    PubMed  CAS  Google Scholar 

  7. Camarasa MA, Olle G, Serra-Prat M, Martín A, Sánchez M, Ricós P, Pérez A, Opisso L. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anaesth. 2006;96:576–582.

    Article  PubMed  CAS  Google Scholar 

  8. Cid J, Lozano M. Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion. 2005;45:1302–1307.

    Article  PubMed  CAS  Google Scholar 

  9. Clements DH, Sculco TP, Burke SW, Mayer K, Levine DB. Salvage and reinfusion of postoperative sanguineous wound drainage: a preliminary report. J Bone Joint Surg Am. 1992;74:646–651.

    PubMed  CAS  Google Scholar 

  10. Dalen T, Brostrom LA, Engtrom KG. Autotransfusion after total knee arthroplasty: effects on blood cells, plasma chemistry, and whole blood rheology. J Arthroplasty. 1997;12:517–525.

    Article  PubMed  CAS  Google Scholar 

  11. Dubber AH, McNicol GP, Douglas AS. Amino methyl cyclohexane carboxylic acid (AMCHA): a new synthetic fibrinolytic inhibitor. Br J Haematol. 1965;11:237–245.

    Article  PubMed  CAS  Google Scholar 

  12. Engel JM, Hohaus T, Ruwoldt R, Menges T, Jürgensen I, Hempelmann G. Regional hemostatic status and blood requirements after total knee arthroplasty with and without tranexamic acid or aprotinin. Anesth Analg. 2001;92:775–780.

    Article  PubMed  CAS  Google Scholar 

  13. Eriksson O, Kjellman H, Pillbrant A, Schannong M. Pharmacokinetics of tranexamic acid after intravenous administration to normal volunteers. Eur J Clin Pharmacol. 1974;7:375–380.

    Article  PubMed  CAS  Google Scholar 

  14. Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg Am. 1981;63:461–465.

    PubMed  CAS  Google Scholar 

  15. Fiebig E. Safety of the blood supply. Clin Orthop Relat Res. 1998;357:6–18.

    Article  PubMed  Google Scholar 

  16. Gannon DM, Lombardi AV Jr, Mallory TH, Vaughn BK, Finney CR, Niemcryk S. An evaluation of the efficacy of postoperative blood salvage after total joint arthroplasty: a prospective randomized trial. J Arthroplasty. 1991;6:109–114.

    Article  PubMed  CAS  Google Scholar 

  17. Gascon P, Zoumbos NC, Young NS. Immunologic abnormalities in patients receiving multiple blood transfusions. Ann Intern Med. 1984;100:173–177.

    PubMed  CAS  Google Scholar 

  18. Gibbons CE, Solan MC, Ricketts DM, Patterson M. Cryotherapy compared with Robert Jones bandage after total knee replacement: a prospective randomized trial. Int Orthop. 2001;25:250–252.

    Article  PubMed  CAS  Google Scholar 

  19. Good L, Peterson E, Lisander B. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth. 2003;90:596–599.

    Article  PubMed  CAS  Google Scholar 

  20. Groh Gl, Buchert PK, Allen WC. A comparison of transfusion requirements after total knee arthroplasty using the Solcotrans autotransfusion system. J Arthroplasty. 1990;5:281–285.

    Article  PubMed  CAS  Google Scholar 

  21. Han CD, Shin DE. Postoperative blood salvage and reinfusion after total joint arthroplasty. J Arthroplasty. 1997;12:511–516.

    Article  PubMed  CAS  Google Scholar 

  22. Heddle NM, Klama LN, Griffith L, Roberts R, Shukla G, Kelton JG. A prospective study to identify the risk factors associated with acute reactions to platelet and red cell transfusions. Transfusion. 1993;33:794–797.

    Article  PubMed  CAS  Google Scholar 

  23. Hiippala ST, Strid LJ, Wennerstrand MI, Arvela JV, Niemelä HM, Mäntylä SK, Kuisma RP, Ylinen JE. Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg. 1997;84:839–844.

    PubMed  CAS  Google Scholar 

  24. Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. 2003;31:529–537.

    PubMed  CAS  Google Scholar 

  25. Howes JP, Sharma V, Cohen AT. Tranexamic acid reduces blood loss after knee arthroplasty. J Bone Joint Surg Br. 1996;78:995–996.

    Article  PubMed  CAS  Google Scholar 

  26. Hoylaerts M, Lijnen HR, Collen D. Studies on the mechanism of antifibrinolytic action of tranexamic acid. Biochim Biophys Acta. 1981;673:75–85.

    PubMed  CAS  Google Scholar 

  27. Hynes M, Calder P, Scott G. The use of tranexamic acid to reduce blood loss during total knee arthroplasty. Knee. 2003;10:375–377.

    Article  PubMed  CAS  Google Scholar 

  28. Jansen AJ, Andreica S, Claeys M, D’Haese J, Camu F, Jochmans K. Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty. Br J Anaesth. 1999;83:596–601.

    PubMed  CAS  Google Scholar 

  29. Janssens M, Joris J, David JL, Lemaire R, Lamy M. High-dose aprotinin reduces blood loss in patients undergoing total hip replacement surgery. Anesthesiology. 1994;80:23–29.

    Article  PubMed  CAS  Google Scholar 

  30. Juelsgaard P, Larsen UT, Sorensen JV, Madsen F, Soballe K. Hypotensive epidural anesthesia in total knee replacement without tourniquet: reduced blood loss and transfusion. Reg Anesth Pain Med. 2001;26:105–110.

    PubMed  CAS  Google Scholar 

  31. Klenerman L, Chakrabarti R, Mackie I, Brozovic M, Stirling Y. Changes in haemostatic system after application of a tourniquet. Lancet. 1977;1:970–972.

    Article  PubMed  CAS  Google Scholar 

  32. Kruithof EK, Nicolosa G, Bachmann F. Plasminogen activator inhibitor 1: development of a radioimmunoassay and observations on its plasma concentration during venous occlusion and after platelet aggregation. Blood. 1987;70:1645–1653.

    PubMed  CAS  Google Scholar 

  33. Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski H. The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty: a prospective, randomized, multicenter study. J Bone Joint Surg Am. 1999;81:1580–1588.

    PubMed  CAS  Google Scholar 

  34. Martin JW, Whiteside LA, Milliano MT, Reedy ME. Postoperative blood retrieval and transfusion in cementless total knee arthroplasty. J Arthroplasty. 1992;7:205–210.

    Article  PubMed  CAS  Google Scholar 

  35. Molloy DO, Archbold HA, Ogonda L,McConway J, Wilson RK, Beverland DE. Comparison of topical fibrin spray and tranexamic acid on blood loss after total knee replacement: a prospective randomised controlled trial. J Bone Joint Surg Br. 2007;89:306–309.

    Article  PubMed  CAS  Google Scholar 

  36. Nakahara M, Sakahashi H. Effect of application of a tourniquet on bleeding factors in dogs. J Bone Joint Surg Am. 1967;49:1345–1351.

    PubMed  CAS  Google Scholar 

  37. Newman JH, Bowers M, Murphy J. The clinical advantages of autologous transfusion: a randomized, controlled study after knee replacement. J Bone Joint Surg Br. 1997;79:630–632.

    Article  PubMed  CAS  Google Scholar 

  38. Nilsson IM. Clinical pharmacology of aminocaproic and tranexamic acids. J Clin Pathol Suppl (R Coll Pathol). 1980;14:41–47.

    CAS  Google Scholar 

  39. Orpen NM, Little C, Walker G, Crawfurd EJ. Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomised controlled trial of 29 patients. Knee. 2006;13:106–110.

    Article  PubMed  Google Scholar 

  40. Petaja J, Myllynen P, Myllyla G, Vahtera E. Fibrinolysis after application of a pneumatic tourniquet. Acta Chir Scand. 1987;153:647–651.

    PubMed  CAS  Google Scholar 

  41. Prasad N, Padmanabhan V, Mullaji A. Comparison between two methods of drain clamping after total knee arthroplasty. Arch Orthop Trauma Surg. 2005;125:381–384.

    Article  PubMed  Google Scholar 

  42. Raleigh E, Hing CB, Hanusiewicz AS, Fletcher SA, Price R. Drain clamping in knee arthroplasty: a randomized controlled trial. ANZ J Surg. 2007;77:333–335.

    Article  PubMed  Google Scholar 

  43. Raut VV, Stone MH, Wroblewski BM. Reduction of postoperative blood loss after press-fit condylar knee arthroplasty with use of a femoral intramedullary plug. J Bone Joint Surg Am. 1993;75:1356–1357.

    PubMed  CAS  Google Scholar 

  44. Risberg B. The response of the fibrinolytic system in trauma. Acta Chir Scand Suppl. 1985;522:245–271.

    PubMed  CAS  Google Scholar 

  45. Roy N, Smith M, Anwar M, Elsworth C. Delayed release of drain in total knee replacement reduces blood loss: a prospective randomised study. Acta Orthop Belg. 2006;72:34–38.

    PubMed  Google Scholar 

  46. Ryu J, Sakamoto A, Honda T, Saito S. The postoperative drain-clamping method for hemostasis in total knee arthroplasty: reducing postoperative bleeding in total knee arthroplasty. Bull Hosp Jt Dis. 1997;56:251–254.

    PubMed  CAS  Google Scholar 

  47. Sakahashi H, Sato E, Ishima T. A means for control of bleeding during and after the artificial knee joint replacement operation (combined use of antiplasmin and the drain clamp method). Jpn Soc Replacement Arthroplasty. 1998;28:67–68.

    Google Scholar 

  48. Sakihara H. [A method to control postoperative bleeding after total knee replacement] [in Japanese]. Seikei-saigaigeka. 1988;31:543–545.

    Google Scholar 

  49. Sano M, Hakusui H, Kojima C, Akimoto T. Absorption and excretion of tranexamic acid following intravenous, intramuscular and oral administrations in healthy volunteers. Jpn J Clin Pharmacol Therapeutics. 1976;7:375–382.

    CAS  Google Scholar 

  50. Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion transmitted viral infections: the Retrovirus Epidemiology Donor Study. N Engl J Med. 1996;334:1685–1690.

    Article  PubMed  CAS  Google Scholar 

  51. Shen PC, Jou IM, Lin YT, Lai KA, Yang CY, Chern TC. Comparison between 4-hour clamping drainage and nonclamping drainage after total knee arthroplasty. J Arthroplasty. 2005;20:909–913.

    Article  PubMed  Google Scholar 

  52. Sinha A, Sinha M, Burgert S. Reinfusion of drained blood as an alternative to homologous blood transfusion after total knee replacement. Int Orthop. 2001;25:257–259.

    Article  PubMed  CAS  Google Scholar 

  53. Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br. 2001;83:702–705.

    Article  PubMed  CAS  Google Scholar 

  54. Tsumara N, Yoshiya S, Chin T, Shiba R, Kohso K, Doita M. A prospective comparison of clamping the drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty. J Bone Joint Surg Br. 2006;88:49–53.

    Article  PubMed  CAS  Google Scholar 

  55. Veien M, Sorensen JV, Madsen F, Juelsgaard P. Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized, controlled study. Acta Anaesthesiol Scand. 2002;46:1206–1211.

    Article  PubMed  CAS  Google Scholar 

  56. Verstraete M. Clinical application of inhibitors of fibrinolysis. Drugs. 1985;29:236–261.

    Article  PubMed  CAS  Google Scholar 

  57. Walzman M, Bonnar J. Effects of tranexamic acid on the coagulation and fibrinolytic systems in pregnancy complicated by placental bleeding. Arch Toxicol Suppl. 1982;5:214–220.

    PubMed  CAS  Google Scholar 

  58. Wang GJ, Hungerford DS, Savory CG, Rosenberg AG, Mont MA, Burks SG, Mayers SL, Spotnitz WD. Use of fibrin sealant to reduce bloody drainage and hemoglobin loss after total knee arthroplasty: a brief note on a randomized prospective trial. J Bone Joint Surg Am. 2001;83:1503–1505.

    PubMed  Google Scholar 

  59. Yamada K, Imaizumi T, Uemura M, Takada N, Kim Y. Comparison between 1-hour and 24-hour drain clamping using diluted epinephrine solution after total knee arthroplasty. J Arthroplasty. 2001;16:458–462.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Associate Professor Vatanachai Rojvanit and Associate Professor Areesak Chotivichit for supervision and Suthipol Udompunthurak from the Statistics Division of Siriraj Hospital for statistical analysis.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Keerati Charoencholvanich MD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Charoencholvanich, K., Siriwattanasakul, P. Tranexamic Acid Reduces Blood Loss and Blood Transfusion after TKA: A Prospective Randomized Controlled Trial. Clin Orthop Relat Res 469, 2874–2880 (2011). https://doi.org/10.1007/s11999-011-1874-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-011-1874-2

Keywords

Navigation