Bleeding In Total Knee Arthroplasty Research Articles

Sevoflurane Preconditioning and Total Knee Arthroplasty Bleeding: Randomized Controlled Trial

Background: Total knee arthroplasty (TKA) is a highly complex and effective surgery even though its perioperative bleeding may increase the need for blood transfusion and its associated infection risk, cardiovascular overload, increased costs, and mortality. As the tourniquet reduces intraoperative bleeding, it may be associated with postoperative bleeding, venous thrombosis, and distal ischemia. The reperfusion may trigger a local and systemic inflammatory response. Anesthetic preconditioning (APC) with sevoflurane minimizes ischemia-reperfusion syndrome (IRS). This study evaluated the effects of APC with sevoflurane on perioperative bleeding in TKA. Methods: We allocated 30 patients into two groups: a sevo group (sevoflurane 2% for 15 minutes before the tourniquet) and a control group (propofol infusion). Laboratory tests were collected right before the tourniquet (LAB PRE, in the operating room) and after its release at four moments: LAB POST (immediately after), LAB 2 (two hours after), LAB 12 (12 hours after), and LAB 24 (24 hours after). The volume of the suction drain was measured at one, two, 12, and 24 hours after the end of the surgery. Antifibrinolytics were not administered. Results: There was no statistically significant difference in bleeding-related variables, such as drained volume and hemoglobin and hematocrit measurements. Drainage volume was higher in the first two hours after the procedure, while hematocrit decreased pre- to postoperatively and between two and 12 hours post-procedure. Conclusion: Sevoflurane as an anesthetic preconditioning did not reduce postoperative bleeding in TKA surgery.

Efficacy of a Combined Intramedullary, Periarticular Injection, and Intraarticular Tranexamic Acid Application on Postoperative Bleeding in Total Knee Arthroplasty: A Retrospective Case-Matched Study.

Topical tranexamic acid (TXA) has been widely used to reduce postoperative blood loss following total knee replacement (TKA). This study aimed to evaluate the effect of combined intramedullary, periarticular injection, and intraarticular TXA application in patients who underwent TKA as compared to those who did not. This was a retrospective case-matched study of 111 patients. We evaluated the transfusion rate and postoperative drainage of 56 patients who underwent TKA using combined topical tranexamic acid application (directly pushed into the femoral intramedullary canal and tibia base, with periarticular soft tissue injection and injected into the knee cavity via a drain tube) and the control group of 55 patients. In the control and TXA groups, 7.14% and 1.81% of the patients received blood transfusions, respectively (p=0.176). The closed-suction drainage output at 0-8 h and total drainage output were significantly lower in the TXA group than those in the control group (p < 0.001). Application of topical TXA with the combined method (intramedullary, periarticular injection, and intraarticular) in TKA decreases postoperative suction drainage and may reduce the need for postoperative blood transfusion.

Effect of patellar resurfacing surgery on bleeding in total knee arthroplasty.

Postoperative bleeding is one of the most important factors affecting clinical and functional results in total knee arthroplasty. Therefore, many studies have been conducted on bleeding in arthroplasty patients. However, there are very few reports investigating the effect of patellar surface replacement on bleeding in knee arthroplasty. We, therefore, aimed to investigate the effect of patellar surface replacement on postoperative bleeding. In this retrospective study, 30 with patellar resurfacing were compared with 39 without patellar resurfacing among patients who had undergone total knee replacement due to primary osteoarthritis. Demographic data, amount of transfusion, preoperative and postoperative hemoglobin and hematocrit values, and total, visible, and hidden blood loss values were recorded. No statistical difference was found between the two groups in terms of demographic values. There was no significant difference between the groups in terms of the amount of blood in the drain, total blood loss, hidden blood loss, and blood transfusion in patients who had and had not undergone patellar resurfacing. A positive significant correlation was found between postoperative drainage volume and total blood loss. Patellar component application in patients who had undergone total knee arthroplasty does not change the blood loss of the patients.

TranexAMIC Acid Associated with Less Wound Complications in Hindfoot Surgery

Category:Hindfoot; AnkleIntroduction/Purpose:Tranexamic acid (TXA) is an increasingly popular antifibrinolytic therapy used to decrease bleeding during surgery and postoperative swelling. TXA has been shown to decrease bleeding in total knee arthroplasty and total hip arthroplasty, and is now routinely administered in many centers performing these operations. To date, there is very limited data on its use in foot and ankle surgery. We sought to review of the effect of TXA on outcomes of total ankle arthroplasty (TAA), hindfoot fusions, and other related hindfoot surgeries, with the hypothesis that patients receiving TXA would exhibit fewer wound complications.Methods:We conducted a retrospective review of 252 patients (258 operations) undergoing hindfoot fusions and/or TAA between 2015 and 2020 by a single fellowship trained foot and ankle surgeon at an academic medical center. Twenty-seven patients (28 operations) were excluded for less than 90-day follow-up, leaving 230 eligible procedures (TAA=72, subtalar fusion=47, ankle fusion=37, double arthrodesis=33, tibiotalocalcaneal fusion=20, triple arthrodesis=8, total talus=4, and hardware removal=8). Patient demographics, ASA scores, comorbidities, pre-operative diagnoses, smoking status, wound complications, union status (for fusions), readmissions and reoperations were recorded and compared between TXA (n=104) and non-TXA (n=126) cohorts. Subgroup analysis was performed for TAAs and hindfoot fusions. Mean follow-up was 453 days. Continuous variables were compared using independent sample t-test, and categorical variables with chi-square test, unless more than 20% of expected values were less than 5, in which case Fisher's exact tests were utilized.Results:There were no significant differences in demographics, comorbidities, preoperative diagnoses or smoking status between cohorts. The TXA group exhibited significantly less postoperative infections requiring oral antibiotics (5.8% vs. 15.1%, p=.024).These included superficial (p=.174) and deep infections requiring reoperation (p=.095). Subgroup analysis of hindfoot fusions (n=146) revealed significantly shorter time to fusion between TXA and non-TXA groups (146 vs. 202 days, p=.049) and fewer reoperations (8.6% vs. 21.6%, p=.042). TXA fusion patients had significantly shorter follow-up (349 vs. 479 days, p=.020), fewer active smokers (5.2% vs. 15.9%, p=.048), but more patients with Charcot neuroarthropathy (20.7% vs. 5.7%, p=.006). Subgroup analysis of TAAs showed fewer infections requiring oral antibiotics (4.7% vs. 31%, p=.005) and less delayed wound healing (25.6% vs. 48.3%, p=.047) in the TXA cohort.Conclusion:We found TXA use in hindfoot surgery to correlate with a reduction in wound infections requiring antibiotics and quicker time to union in hindfoot fusions. Further, the use of TXA in TAA specifically was correlated with fewer infections requiring antibiotics and lower rates of delayed wound healing. These reductions were both statistically and clinically significant. TXA has already been shown to be beneficial in other areas of orthopaedic surgery and appears to also be quite beneficial in foot and ankle surgery, though further research is needed to confirm these findings.

The role of suction drainage in the management of peri-operative bleeding in Total and Unicompartmental knee arthroplasty: a retrospective comparative study

BackgroundSuction drainage is commonly applied after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) to reduce hematoma, swelling and to favor surgical wound healing. However, its efficacy remains controversial; thus, the purpose of this study is to evaluate drainage efficiency in the management of postoperative bleeding in TKA and UKA.MethodsThe cohort comprised 134 clinical records of patients affected by knee osteoarthritis (OA) who underwent either TKA or UKA. All the patients were subdivided into 2 groups: the first one with drainage and the second one without drainage (respectively 61 and 73 patients). For each group, hemoglobin levels in the preoperative, first, second and third postoperative day were collected. Postoperative complications such as swelling, bleeding from the surgical wound or the need for blood transfusion, were also recorded.ResultsOur results did not show any significant difference of hemoglobin levels in the first (p = 0.715), second (p = 0.203) and third post-operative day (p = 0.467) between the two groups. Moreover, no significant correlation between knee swelling or transfusion rate and the drainage was observed (p = 0.703 and p = 0.662 respectively). Besides, a significant correlation was found between bleeding from the surgical wound and the absence of drainage (p = 0.006).ConclusionsThe study demonstrates how the routine use of suction drainage does not provide substantial benefits in the postoperative blood loss management after TKA or UKA.Trial registrationClinicalTrials.gov NCT04508101, 09/08/2020, Retrospectively registeredLevel of evidenceIII

Comparison of two doses of intra-articular tranexamic acid on postoperative bleeding in total knee arthroplasty: a randomized clinical trial

IntroductionTranexamic Acid (TXA), an antifibrinolytic that inhibits the fibrinolytic activity of plasmin is used to decrease perioperative blood loss and transfusion requirements in orthopedic surgery. The aim of our study was to compare postoperative bleeding in two intra-articular doses (1g and 2g) of tranexamic acid in adult patients undergoing unilateral total knee replacement. MethodWe conducted a single-operator, randomized, and controlled, double-blind study in two groups. The G1 group received 1g of intra-articular TXA and the G2 group 2g of intra-articular TXA. Both groups received 15mgkg−1 IV before the surgical incision (TXA induction dose) and then 10mgkg−1, orally, 6 and 12hours after the induction dose of TXA.The primary endpoint was bleeding measured by blood loss in postoperative drainage. Secondary outcomes were change in hemoglobin and hematocrit levels on the first and third postoperative days, and the need for transfusion during hospitalization. ResultsIn total, 100 patients were randomized, and 100 were included in the analysis. Blood loss in postoperative drainage was similar in both groups (200±50 vs. 250±50mL, G1 and G2 groups respectively). Change in hematocrit and hemoglobin values (% of change) between preoperative and day 3 were not statically significant between groups G1 and G2 (18±5 vs. 21±4; 21±7 vs. 22±5 respectively). No patients received blood transfusion. ConclusionsOur study did not show superiority of 2g of intra-articular tranexamic acid compared to 1g.ClinicalTrials.gov Identifier NCT04085575

Clinical trial on the effect of tranexamic acid on bleeding and fibrinolysis in primary hip and knee replacement

Abstract Background Tourniquet-induced ischaemia could increase fibrinolysis and enhance tranexamic acid (TXA) efficacy in total knee arthroplasty (TKA) compared to total hip arthroplasty (THA). The aims of this study are to compare the effect of TXA on bleeding and fibrinolysis in both types of surgery, and to record thromboembolic complications. Methods A prospective double-blind study was conducted on patients scheduled for TKA or THA who received TXA (2 bolus of 10 mg/kg) or placebo. Bleeding and fibrinolysis were evaluated. Doppler-ultrasound and computed tomography were performed in order to assess any thromboembolic complications. Results A total of 44 patients were included (11 THA and 11 TKA treated with TXA; 11 THA and 11 TKA as controls). Blood losses were significantly lower in the TXA group (mean 921 mL vs 1383 mL in THA and 969 mL vs 1223 mL in TKA), and no transfusions were needed with TXA, whereas 5 blood units were transfused in controls. TXA was equally effecting in reducing bleeding in both surgeries (33% in THA and 21% in TKA). The significant mean increase in d -dimers from baseline to 6 h after surgery (1004 μg/L to 10,284 μg/L in THA and 571 μg/L to 6480 μg/L in TKA) was attenuated by TXA (1077 μg/L to 2590 μg/L in THA and 655 μg/L to 2535 μg/L in TKA). There were no differences in thromboembolic episodes. Conclusions Prophylactic use of tranexamic acid is equally effective in reducing bleeding in TKA and THA. Both surgeries have a similar effect on fibrinolysis.

Ensayo clínico sobre el efecto del ácido tranexámico en el sangrado y la fibrinólisis durante la artroplastia simple de cadera y rodilla

BackgroundTourniquet-induced ischaemia could increase fibrinolysis and enhance tranexamic acid (TXA) efficacy in total knee arthroplasty (TKA) compared to total hip arthroplasty (THA). The aims of this study are to compare the effect of TXA on bleeding and fibrinolysis in both types of surgery, and to record thromboembolic complications. MethodsA prospective double-blind study was conducted on patients scheduled for TKA or THA who received TXA (2 bolus of 10mg/kg) or placebo. Bleeding and fibrinolysis were evaluated. Doppler-ultrasound and computed tomography were performed in order to assess any thromboembolic complications. ResultsA total of 44 patients were included (11 THA and 11 TKA treated with TXA; 11 THA and 11 TKA as controls). Blood losses were significantly lower in the TXA group (mean 921mL vs 1,383mL in THA and 969mL vs 1,223mL in TKA), and no transfusions were needed with TXA, whereas 5 blood units were transfused in controls. TXA was equally effecting in reducing bleeding in both surgeries (33% in THA and 21% in TKA). The significant mean increase in D-dimers from baseline to 6 hours after surgery (1,004 ug/L to 10,284 ug/L in THA and 571 ug/L to 6,480 ug/L in TKA) was attenuated by TXA (1,077 ug/L to 2,590 ug/L in THA and 655 ug/L to 2,535 ug/L in TKA). There were no differences in thromboembolic episodes. ConclusionsProphylactic use of tranexamic acid is equally effective in reducing bleeding in TKA and THA. Both surgeries have a similar effect on fibrinolysis.

Quantitative efficacy of topical administration of tranexamic acid on postoperative bleeding in total knee arthroplasty

Topical tranexamic acid (TXA) is used in patients undergoing total knee arthroplasty to reduce perioperative blood loss. However, the optimal dosing regimen remains undetermined. The aim of the present study was to quantitatively evaluate the effect of topical TXA on the reduction of postoperative drainage, and identify the dosing regimen factors affecting the efficacy of topical TXA. Model-based meta-analysis was used to evaluate the efficacy of topical TXA and the dosing regimen factors influencing clinical efficacy. Data from a systemic literature search was identified and used to build a time-effect model for placebo and TXA in treating perioperative blood loss. Fourteen studies containing 16 TXA-control groups of drainage volume data were included for MBMA modelling. The model described the postoperative drainage-time profiles adequately. According to the model estimation, TXA can finally reduce the postoperative drainage by about 41.7%, and 10.9 h was needed to reach 50% of the maximal drainage volume. Covariate analysis indicated that both dose and contact time alone did not correlate well with clinical efficacy. However, when considered together, they can dramatically improve fitting of the data. Simulation showed that increasing dose or contact time extensively would produce a plateau-like effect: 2-3 g TXA with contact time of 1-2 h would yield >60% reduction in the drainage volume. Dose and contact time together determined the efficacy of TXA. Extensively large dose or long contact time seems unnecessary. These findings may further guide the clinical practice on the topical TXA regimen optimization.

Topical versus intravenous tranexamic acid in total knee arthroplasty: a meta-analysis of randomized controlled trials.

Tranexamic acid (TXA) is an antifibrinolytic drug used widely to prevent bleeding in total knee arthroplasty (TKA). However, there is no consensus regarding the administration routes of TXA. This meta-analysis aimed to investigate the efficacy of topical (intra-articular) versus intravenous TXA in reducing blood loss and transfusion rate in patients who underwent TKA. We conducted a Pubmed, EMBASE, Cochrane Library, and Web of Science search for randomized controlled trials (RCTs) comparing topical versus intravenous TXA in TKA. Two authors conducted selection of studies, data extraction, and assessment of risk of bias independently. A pooled meta-analysis was performed using RevMan 5.3 software. Sixteen RCTs with a total of 1330 patients were included. Current meta-analysis indicated that there were no significant differences in total blood loss (MD = -41.64ml; 95% CI: -163.43ml to 80.18ml; P = 0.50), drain output (MD = 22.44, 95% CI: -11.18 to 56.06, P = 0.19), transfusion rate (RR = 0.89, 95% CI: 0.62 to 1.27, P = 0.52), the drop of Hb level at post-operative day 1 (MD = 0.26, 95% CI -0.03 to 0.55, P = 0.03), day 2 (MD = -0.08, 95% CI -0.76 to 0.59, P = 0.81), day 3 (MD = -0.20, 95% CI -0.77 to 0.37, P = 0.49), and length of stay (MD = -0.10; 95% CI: -0.17 to -0.02; P = 0.02) between the topical group and intravenous group. In addition, no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis (RR = 1.08, 95% CI: 0.48 to 2.40, P = 0.86), pulmonary embolism (RR = 0.56, 95% CI: 0.05 to 5.99, P = 0.63), wound complications (RR = 0.56, 95% CI: 0.05 to 5.99, P = 0.63), and infection (RR = 0.74, 95% CI: 0.30 to 1.85, P = 0.52) between the two groups. Our meta-analysis of 16 RCTs revealed that both topical TXA and intravenous TXA are effective in reducing blood loss and transfusion rates in patients who underwent TKA.

Platelet-rich plasma for the reduction of blood loss after total knee arthroplasty: a clinical trial.

This study aims to clarify the effect of intra-articular platelet-rich plasma (PRP) in total knee arthroplasty (TKA) in preventing postoperative bleeding. There were 315 knees that underwent TKA and were included in this study. The subjects were randomized by paramedical staffs. These were divided into the PRP group who received intra-articular PRP intraoperatively (n=109) and the control group who did not (n=206). We measured postoperative blood loss (drain bag volume), estimated blood loss, and change in hemoglobin (Hb) value at postoperative day 1, 2, 4, and 7. The clinical data were compared between the PRP group and the control group. The mean postoperative blood loss of 446.9±149.7mL in the PRP group was significantly less than that in the control group (550.7±178.1mL, p<0.001). The mean postoperative estimated blood loss of 437.5±221.3mL in the PRP group was significantly less than that in the control group (552.2±336.3mL, p<0.01). The mean change in Hb value (mg/dL) from baseline was -1.45 in the PRP group and -1.85 in the control group at postoperative 1day (p<0.05), -1.74 in the PRP group and -2.11 in the control group at postoperative day 2 (p<0.05), -2.30 in the PRP group and -2.47 in the control group at postoperative day 4 (p<0.05), and -1.98 in the PRP group and -2.46 in the control group at postoperative day 7 (p<0.01). In this prospective randomized study, those that received PRP after TKA had significantly less postoperative blood loss and change in Hb level. PRP appears to be effective in reducing postoperative bleeding in TKA.

Three-hour interval drain clamping reduces postoperative bleeding in total knee arthroplasty: a prospective randomized controlled trial

Total knee arthroplasty (TKA) is a common procedure that has a risk of significant blood loss and blood transfusion, and carries a substantial risk for immunologic reactions and disease transmission. Drain clamping is a popular method that is applied to reduce blood loss after TKA. However, the clamping protocol remains controversial. Therefore, we established a new protocol, 3-h interval clamping, and compared the bleeding control efficacy of this protocol following TKA with the non-clamping technique. Between March and July 2008, we enrolled 100 patients (100 knees) who underwent uncomplicated TKA using a minimally invasive surgical technique. The patients were randomly assigned into two groups based on the draining protocol: non-clamping (group A) and 3-h interval clamping (group B). For group A, a vacuum drain was connected to a container and was run continuously during the first postoperative day, whereas the vacuum was stopped twice (for ~3h each time) for group B. Demographic characteristics and clinical data were collected, including the levels of hemoglobin and hematocrit, the total blood loss volume, the number of patients who required a blood transfusion, and any complications that developed. The perioperative data were compared between the two groups. The drainage blood volume in the interval-clamping group (group B) was significantly lower than that in the non-clamping group (group A) during the first 48h following the procedure (p<0.001 and p=0.005 for first and second postoperative days, respectively). The mean fall in hemoglobin levels at 12h in the interval-clamping group (2.8±0.9g/dL) was also lower than in the non-clamping group (3.2±0.8g/dL). In the 3-h interval clamping protocol, the number of patients requiring a transfusion was 2.2 times less than the number in the non-clamping protocol, but was not significantly different (odds ratio=2.20, p=0.24), and the significant predictor of blood transfusion was the preoperative hemoglobin level (odds ratio=7.73, p<0.001). No wound infection or clinical venous thromboembolisms were detected in our study. The 3-h interval clamping is a newly developed protocol for reducing blood loss after TKA. The protocol lessens the decrease in postoperative hemoglobin levels. This protocol can be applied easily without increasing clinical thromboembolic events and wound complications.

The Influence of Tourniquet Use and Timing of its Release on Blood Loss in Total Knee Arthroplasty

In surgical practice, hemostasis is used to minimize postoperative bleeding in total knee arthroplasty. We performed a prospective randomized study to determine the influence of tourniquet use and the timing of its release on amount of bleeding. Eighty four patients (96 knees) were scheduled for total knee arthroplasty and randomly divided into three groups. Posterior cruciate retaining bicompartmental total knee prostheses were used in all. In group I, no tourniquet was used. In group II, a tourniquet was used and was deflated for hemostasis once all components had been inserted. In group III, the tourniquet was deflated after wound closure and application of a compressive dressing. Mean blood drainage, mean volume of blood transfusion, hemoglobin (Hb) and hematocrit (Hct) values and operative time were compared between the three groups. Mean blood drainage was 810 mL (300-1300) in groups I 720 mL (240-1200) in group II and 705 mL (250-1150) in group III (p = 0.062). The Hb and Hct values, tourniquet time (for groups II and III) and volume of blood transfusion were similar. The operative time was significantly longer for first group (p = 0.012). Using tourniquet and its intraoperative release with hemostasis, does not reduce blood loss in total knee arthroplasty, but using tourniquet reduces operation time significantly.

Local infusion of norepinephrine reduces blood losses and need of transfusion in total knee arthroplasty

Blood loss after total knee arthroplasty (TKA) is often associated with cardiovascular complications and a high transfusion rate of allogenic blood. In our study we focused our attention on developing a new intra-surgical procedure that appears safe, easy to perform and effective in the reduction of bleeding in TKA. We evaluated 84 patients who underwent TKA and met our inclusion criteria; they were assigned to two groups: 55 controls in which a saline solution was used to wash the surgical field before tourniquet release, and a second group of 29 patients, in which a saline solution containing a low dose of norepinephrine was locally applied before tourniquet release. The local administration of a low dose of norepinephrine has induced a significant reduction of perioperative blood loss and blood transfusion requirements; in addition, this method was characterised by the absence of complications or adverse effects. In conclusion, our data suggest that intraoperative local administration of a low dose of norepinephrine could represent an effective and safe method of reducing blood loss and preventing blood transfusions in patients with TKA.