The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

A Comparison Of Oral Vs Intravenous Tranexamic Acid In Patients Undergoing Staggered Bilateral Total Knee Arthroplasty

Document Type : RESEARCH PAPER

Authors
Ali J Electricwala 1
Rumi Dasgupta 2
Sameer V Kulkarni 1
Jaffer T Electricwala 1
1 Electricwala Hospital, Pleasant Park D Building, Pune, Maharashtra, India
2 Essence Medical Centre, Westwinds, Westwinds Dr. NE, Calgary, Alberta, Canada
10.22038/abjs.2021.49561.2459
Abstract
Background: All previous studies comparing the blood sparing efficacy oral and intravenous tranexamic acid (TXA) in 
total knee arthroplasty have involved two or more patient cohorts, outcomes of which may be limited by inter-individual 
variability in human drug response. The purpose of this study was to evaluate if both oral and intravenous preparations 
of TXA are equivalent at reducing blood loss in the same patients undergoing staggered bilateral total knee arthroplasty.
Methods: 40 patients undergoing staggered bilateral total knee replacement were recruited. They received 2 g of oral 
TXA 2 hours preoperatively for the first knee and 1 g of bolus intravenous TXA 15 minutes before skin incision for the 
second knee. 7 patients were excluded for protocol deviation, leaving 33 participants for the study. The second knee 
was operated within 5-6 days of the first knee. The primary outcome was reduction in hemoglobin. Equivalence was 
tested with a two one-sided test (TOST) and a P < 0.05 indicated equivalence between oral and intravenous modes of 
TXA administration. 
Results: The mean reduction in hemoglobin was similar between oral and intravenous mode of TXA administration 
(2.18 and 2.16 g/dl respectively, P<0.0001, equivalence). There was no significant difference in the total hemoglobin 
loss and total red blood cell volume loss {(104 and 102 g, P=0.86) and (865 and 863 ml, P=0.53) respectively}. 
Conclusion: Oral and intra venous TXA have equal blood sparing properties in patients undergoing staggered bilateral 
total knee arthroplasty.
Level of evidence: II
Keywords
ntravenous
Oral
Staggered bilateral
TXA
Total knee arthroplasty
  1. Ponnusamy KE, Kim TJ, Khanuja HS. Perioperative blood transfusions in orthopaedic surgery. J Bone Joint Surg Am. 2014; 96(21):1836-44.
  2. Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. The Lancet. 1996; 348(9034):1055-60.
  3. Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic therapy and perioperative considerations. Anesthesiology. 2018; 128(3):657-70.
  4. Xie J, Ma J, Yue C, Kang P, Pei F. Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial. Hip International. 2016; 26(1):36-42.
  5. Sridharan K, Sivaramakrishnan G. Tranexamic acid in total hip arthroplasty: a recursive cumulative meta-analysis of randomized controlled trials and assessment of publication bias. Journal of orthopaedics. 2017; 14(3):323-8.
  6. Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. European Journal of Anaesthesiology| EJA. 2017; 34(6):332-95.
  7. Nishihara S, Hamada M. Does tranexamic acid alter the risk of thromboembolism after total hip arthroplasty in the absence of routine chemical thromboprophylaxis? The Bone & Joint Journal. 2015; 97(4):458-62.
  8. Fillingham YA, Kayupov E, Plummer DR, Moric M, Gerlinger TL, Della Valle CJ. The James A. Rand Young Investigator’s Award: a randomized controlled trial of oral and intravenous tranexamic acid in total knee arthroplasty: the same efficacy at lower cost? The Journal of arthroplasty. 2016; 31(9):26-30.
  9. Luo ZY, Wang HY, Wang D, Zhou K, Pei FX, Zhou ZK. Oral vs intravenous vs topical tranexamic acid in primary hip arthroplasty: a prospective, randomized, double-blind, controlled study. The Journal of arthroplasty. 2018; 33(3):786-93.
  10. Turner RM, Park BK, Pirmohamed M. Parsing interindividual drug variability: an emerging role for systems pharmacology. Wiley Interdisciplinary Reviews: Systems Biology and Medicine. 2015; 7(4):221-41.
  11. Sweeney GD. Variability in the human drug response. Thrombosis Research. 1983; 29:3-15.
  12. Gurunathan U. Staggered bilateral knee arthroplasty: good or bad? Anesthesiology. 2010; 113(1):256-8.
  13. Morris JK, Fincham BM. Intermittent pneumatic compression for venous thromboembolism prophylaxis in total knee arthroplasty. Orthopedics. 2012; 35(12):e1716-21.
  14. Crawford DA, Andrews RL, Morris MJ, Hurst JM, Lombardi Jr AV, Berend KR. Ambulatory portable pneumatic compression device as part of a multimodal aspirin-based approach in prevention of venous thromboembolism in outpatient total knee arthroplasty. Arthroplasty today. 2020; 6(3):378-80.
  15. Algadiem EA, Aleisa AA, Alsubaie HI, Buhlaiqah NR, Algadeeb JB, Alsneini HA. Blood loss estimation using gauze visual analogue. Trauma monthly. 2016; 21(2).
  16. Gao FQ, Li ZJ, Zhang K, Sun W, Zhang H. Four methods for calculating blood-loss after total knee arthroplasty. Chinese medical journal. 2015; 128(21):2856-60.
  17. 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. British journal of Anaesthesia. 1999; 83(4):596-601.
  18. Benoni G, Fredin HA. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients. The Journal of bone and joint surgery. British volume. 1996; 78(3):434-40.
  19. Irwin A, Khan SK, Jameson SS, Tate RC, Copeland C, Reed MR. Oral versus intravenous tranexamic acid in enhanced-recovery primary total hip and knee replacement: results of 3000 procedures. The Bone & Joint Journal. 2013; 95(11):1556-61.
  20. Jules-Elysee KM, Tseng A, Sculco TP, Baaklini LR, McLawhorn AS, Pickard AJ, et al. Comparison of topical and intravenous tranexamic acid for total knee replacement: a randomized double-blinded controlled study of effects on tranexamic acid levels and thrombogenic and inflammatory marker levels. The Journal of bone and joint surgery. American volume. 2019; 101(23):2120.
  21. Guo P, He Z, Wang Y, Gao F, Sun W, Guo W, et al. Efficacy and safety of oral tranexamic acid in total knee arthroplasty: a systematic review and meta-analysis. Medicine. 2018; 97(18).
  22. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, et al. The efficacy of tranexamic acid in total knee arthroplasty: a network meta-analysis. The Journal of arthroplasty. 2018; 33(10):3090-8.
  23. Xiong H, Liu Y, Zeng Y, Wu Y, Shen B. The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC musculoskeletal disorders. 2018; 19(1):1-1.
  24. Wang D, Luo ZY, Yu ZP, Liu LX, Chen C, Meng WK, et al. The antifibrinolytic and anti-inflammatory effects of multiple doses of oral tranexamic acid in total knee arthroplasty patients: a randomized controlled trial. Journal of Thrombosis and Haemostasis. 2018; 16(12):2442-53.
The Archives of Bone and Joint Surgery
Volume 10, Issue 3
March 2022
Pages 261-266

  • Receive Date 14 June 2020
  • Revise Date 18 July 2021
  • Accept Date 03 August 2021