Abstract
Background
Tranexamic acid (TA) use in lower‑limb arthroplasty has been valued in these surgeries high‑risk hemorrhagic due to its antifibrinolytic action. The objective of the present study was to determine the effectiveness of the combined intravenous (IV) and intraarticular (IA) administration of TA in lower‑limb arthroplasty.
Methods
We conduct a prospective observational study between January 1, 2014, and December 31, 2017, including all programmed lower‑limb arthroplasties. Patients were divided into four groups: no TA, 15 mg/kg IV TA, 3 g IA TA, and 15 mg/kg IV and 3 g IA. The effect on calculated total blood loss (milliliter of red blood cell [RBC]), hemoglobin, transfusion, and duration of hospitalization was studied after adjustment on age, American Society of Anesthesiologists, surgery, and postoperative curative anticoagulation. Complications related to TA administration were systematically reported.
Results
A total of 1909 patients were included – “no TA,” n = 184; “IV,” n = 1137; “IA,” n = 214; and “IV + IA,” n = 374. In the IV + IA group, a decrease in blood loss was observed compared to the no TA group (+ 220 ml 95% confidence interval [CI] [184; 255] of RBC P < 0.001) and in the IA group (+ 65 ml 95% CI [30; 99] of RBC P < 0.001). The length of hospital stay of the IV + IA group was shorter compared to the no TA group (hazard ratio [HR] 0.35, 95% CI [0.29; 0.43], P < 0.001) to the IA group (HR 0.57, 95% CI [0.48; 0.69], P < 0.001) and the IV group (HR 0.45, 95% CI [0.39; 0.50], P < 0.001). One case of deep vein thrombosis occurred in the group without TA.
Conclusion
Administration of combined TA appears effective and safe; further studies are needed in order to establish a consensual protocol.
Similar content being viewed by others
References
Kremers, H. M., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., & Steiner, C. A., et al. (2015). Prevalence of total hip and knee replacement in the United States. The Journal of Bone and Joint Surgery, 97(17), 1386–1397
Kurtz, S., Ong, K., Lau, E., Mowat, F., & Halpern, M. (2007). Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. The Journal of Bone and Joint Surgery, 89, 780–785.
Pulido, L., Parvizi, J., Macgibeny, M., Sharkey, P. F., Purtill, J. J., Rothman, R. H., & Hozack, W. J., et al. (2008). In hospital complications after total joint arthroplasty. The Journal of Arthroplasty, 23, 139–145.
Spahn, D. R. (2010). Anemia and patient blood management in hip and knee surgerya systematic review of the literature. Anesthesiology, 113, 482–495.
Hart, A., Abou Khalil, J., Carli, A., Huk, O., Zukor, D., & Antoniou, J. (2014). Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. The Journal of Bone and Joint Surgery, 96, 1945–1951.
Maxwell, M. J., & Wilson, M. J. (2006). Complications of blood transfusion. Continuing Education in Anaesthesia, Critical Care and Pain, 6, 225–229.
Mannucci, P. M., & Levi, M. (2007). Prevention and treatment of major blood loss. New England Journal of Medicine, 356, 2301–2311.
Khan, N., Troelsen, A., & Husted, H. (2015). Prevention of post-operative anaemia in hip and knee arthroplasty--a systematic review. Dan Med J, 62, A5170.
Kagoma, Y. K., Crowther, M. A., Douketis, J., Bhandari, M., Eikelboom, J., & Lim, W. (2009). Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials. Thrombosis Research, 123, 687–696.
Zufferey, P., Merquiol, F., Laporte, S., Decousus, H., Mismetti, P., & Auboyer, C., et al. (2006). Do antifibrinolytics reduce allogeneic blood transfusion in orthopedic surgery? Anesthesiology, 105, 1034–1046.
Alshryda, S., Sukeik, M., Sarda, P., Blenkinsopp, J., Haddad, F. S., & Mason, J. M. (2014). A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. The Bone and Joint Journal, 96-B, 1005–1015.
Jain, N. P., Nisthane, P. P., & Shah, N. A. (2016). Combined administration of systemic and topical tranexamic acid for total knee arthroplasty: can it be a better regimen and yet safe? A randomized controlled trial. The Journal of Arthroplasty, 31, 542–547.
Song, E. K., Seon, J. K., Prakash, J., Seol, Y. J., Park, Y. J., & Jin, C. (2017). Combined administration of IV and topical tranexamic acid is not superior to either individually in primary navigated TKA. The Journal of Arthroplasty, 32, 37–42.
Wu, Y. G., Zeng, Y., Yang, T. M., Si, H. B., Cao, F., & Shen, B. (2016). The efficacy and safety of combination of intravenous and topical tranexamic acid in revision hip arthroplasty: a randomized, controlled trial. The Journal of Arthroplasty, 31, 2548–2553.
Yi, Z., Bin, S., Jing, Y., Zongke, Z., Pengde, K., & Fuxing, P. (2016). Tranexamic acid administration in primary total hip arthroplasty: a randomized controlled trial of intravenous combined with topical versus single-dose intravenous administration. The Journal of Bone and Joint Surgery, 98, 983–991.
Nielsen, C. S., Jans, Ø., Ørsnes, T., Foss, N. B., Troelsen, A., & Husted, H. (2016). Combined intra-articular and intravenous tranexamic acid reduces blood loss in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. The Journal of Bone And Joint Surgery, 98, 835.
Karaaslan, F., Karaoğlu, S., Mermerkaya, M. U., & Baktir, A. (2015). Reducing blood loss in simultaneous bilateral total knee arthroplasty: combined intravenous–intra-articular tranexamic acid administration. A prospective randomized controlled trial. The Knee, 22, 131–135.
Lin, S. Y., Chen, C. H., Fu, Y. C., Huang, P. J., Chang, J. K., & Huang, H. T. (2015). The efficacy of combined use of intraarticular and intravenous tranexamic acid on reducing blood loss and transfusion rate in total knee arthroplasty. The Journal of Arthroplasty, 30, 776–780.
Huang, Z., Ma, J., Shen, B., & Pei, F. (2014). Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. The Journal of Srthroplasty, 29, 2342–2346.
Prakash, J., Seon, J. K., Song, E. K., Lee, D. H., Yang, H. Y., & Jin, C. (2018). Is combined administration of tranexamic acid better than both intravenous and topical regimes for total loss, hidden loss and post-operative swelling? A Randomized control trial. Indian Journal of Orthopaedics, 52, 117–123.
Adravanti, P., Di Salvo, E., Calafiore, G., Vasta, S., Ampollini, A., & Rosa, M. A. (2018). A prospective, randomized, comparative study of intravenous alone and combined intravenous and intraarticular administration of tranexamic acid in primary total knee replacement. Arthroplasty Today, 4, 85–88.
Yang, L., Du, S., & Sun, Y. (2017). Is combined topical and intravenous tranexamic acid superior to single use of tranexamic acid in total joint arthroplasty? A meta-analysis from randomized controlled trials. Medicine (Baltimore), 96, e7609.
Li, J. F., Li, H., Zhao, H., Wang, J., Liu, S., & Song, Y. (2017). Combined use of intravenous and topical versus intravenous tranexamic acid in primary total knee and hip arthroplasty: a meta-analysis of randomised controlled trials. Journal of Orthopaedic Surgery and Research, 12, 22.
Sun, Y., Jiang, C., & Li, Q. (2017). A systematic review and meta-analysis comparing combined intravenous and topical tranexamic acid with intravenous administration alone in THA. PLoS One, 12, e0186174.
Haute Autorité de Santé (2018). Transfusions de Globules Rouges Homologues: produits, Indications, Alternatives. https://www.has-sante.fr/portail/jcms/c_1349939/fr/transfusionsde‑globules‑rouges‑homologues‑produits‑indications‑alternatives. Accessed 30 Apr 2018.
Mercuriali, F., & Inghilleri, G. (1996). Proposal of an algorithm to help the choice of the best transfusion strategy. Current Medical Research and Opinion, 13, 465–478.
Gibon, E., Courpied, J. P., & Hamadouche, M. (2013). Total joint replacement and blood loss: what is the best equation? International Orthopaedics, 37, 735–739.
Andersson, L., Nilsoon, I. M., Colleen, S., Granstrand, J. B., & Melander, B. (1968). Role of urokinase and tissue activator in sustaining bleeding and the management thereof with EACA and AMCA. Annals of the New York Academy of Sciences, 146, 642–656.
Karski, J. M., Dowd, N. P., Joiner, R., Carroll, J., Peniston, C., & Bailey, K., et al. (1998). The effect of three different doses of tranexamic acid on blood loss after cardiac surgery with mild systemic hypothermia (32 C). Journal of Cardiothoracic and Vascular Anesthesia, 12, 642–646.
Wong, J., Abrishami, A., El Beheiry, H., Mahomed, N. N., Davey, J. R., & Gandhi, R., et al. (2010). Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. The Journal of Bone and Joint Surgery, 92, 2503–2513.
Krauss, E. S., Cronin, M., Suratwala, S. J., Enker, P., Rosen, L., & Segal, A. (2017). Use of intravenous tranexamic acid improves early ambulation after total knee arthroplasty and anterior and posterior total hip arthroplasty. The American journal of orthopedics (Belle Mead NJ), 46, E314–E319.
Levy, J. H., Koster, A., Quinones, Q. J., Milling, T. J., & Key, N. S. (2018). Antifibrinolytic therapy and perioperative considerations. Anesthesiology, 128, 657–670.
CRASH-2 trial collaborators, Shakur, H., Roberts, I., Bautista, R., Caballero, J., Coats, T., & Dewan, Y., et al. (2010). Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): A randomised, placebo-controlled trial. Lancet, 376, 23–32.
Henry, D. A., Carless, P. A., Moxey, A. J., O'Connell, D., Stokes, B. J., & Fergusson, D. A., et al. (2011). Anti‐fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews, 1, CD001886.
Acknowledgements
We would like to thanks Mr. Robinson for his work on this article.
Funding
Nil.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
There are no conflicts of interest.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Vacheron, CH., Roy, P., Petit, P.Y. et al. Effectiveness and Safety of the Combined Use of Tranexamic Acid: A Comparative Observational Study of 1909 Cases. JOIO 54 (Suppl 1), 165–171 (2020). https://doi.org/10.1007/s43465-020-00071-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s43465-020-00071-0