Tranexamic acid is associated with selective increase in inflammatory markers following total knee arthroplasty (TKA): a pilot study

Andrea L. Grant,Kaushik Hazratwala,Hayley L. Letson,Peter McEwen,Jodie L. Morris,Matthew Wilkinson,Geoffrey P. Dobson

doi:10.1186/s13018-018-0855-5

Abstract

BackgroundTranexamic acid (TXA) is commonly used in orthopedic surgery to reduce excessive bleeding and transfusion requirements. Our aim was to examine if TXA was required in all osteoarthritis patients undergoing TKA surgery, and its possible effects on systemic inflammation and coagulation properties.MethodsTwenty-three patients (Oxford Score 22–29) were recruited consecutively; 12 patients received TXA before (IV, 1.2 g/90 kg) and immediately after surgery (intra-articular, 1.4 g/90 kg). Inflammatory mediators and ROTEM parameters were measured in blood at baseline, after the first bone-cut, immediately after surgery, and postoperative days 1 and 2.ResultsAfter the bone cut and surgery, TXA significantly increased MCP-1, TNF-α, IL-1β and IL-6 levels compared to non-TXA patients, which was further amplified postoperatively. During surgery, TXA significantly prolonged EXTEM clot times, indicating a thrombin-slowing effect, despite little or no change in clot amplitude or fibrinogen. TXA was associated with three- to fivefold increases in FIBTEM maximum lysis (ML), a finding counter to TXA’s antifibrinolytic effect. Maximum lysis for extrinsic and intrinsic pathways was < 8%, indicating little or no hyperfibrinolysis. No significant differences were found in postoperative hemoglobin between the two groups.ConclusionsTXA was associated with increased systemic inflammation during surgery compared to non-TXA patients, with further amplification on postoperative days 1 and 2. On the basis of little or no change in viscoelastic clot strength, fibrinogen or clot lysis, there appeared to be no clinical justification for TXA in our group of patients. Larger prospective, randomized trials are required to investigate a possible proinflammatory effect in TKA patients.

Highlights

Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce excessive bleeding and transfusion requirements
Lower tourniquet times may be due to differences in surgical procedures among surgeons; it is important to note that possible longer ischemic times in non-TXA patients may exacerbate postoperative inflammation; it was less than TXA-treated patients in our cohort
After the first bone cut and surgery end, Monocyte chemoattractant protein-1 (MCP-1), Tumor necrosis factor alpha (TNF-α), IL-1β and Interleukin 6 (IL-6) were significantly increased in TXA compared to nonTXA patients, with differences further amplified at postoperative days 1 and 2

Summary

Introduction

Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce excessive bleeding and transfusion requirements. A common perioperative complication during knee and hip surgery is excessive bleeding and the need for blood products [1, 2]. TXA is a synthetic lysine analog that reduces active bleeding by blocking the 5 lysine-binding sites on plasminogen, In orthopaedic surgery, two injections of TXA are commonly used; one is given intravenously before the operation, and another in the knee joint on deflation of the tourniquet [7,8,9]. In a recent large retrospective cohort study, involving 872,416 patients, Poeran and colleagues concluded that TXA was effective in reducing the need for blood transfusions during total hip or knee arthroplasty [10]. In 2017, we showed that TXA administration in medium-risk cardiac surgery patients led to anomalous clot behaviour after a sternotomy, lower platelet numbers after surgery, and little or no difference in fibrinolysis compared to non-TXA patients [16]

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