Comparison of Combined Intraarticular and Intravenous Administration of Tranexamic Acid with Intraarticular and Intravenous Alone in Patients Undergoing Total Knee Arthroplasty without Drainage Catheter: A Clinical Trial Study

Document Type : RESEARCH PAPER

Authors

Joint Reconstruction Research Center, Imam Khomeini hospital, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Objectives: We aimed to assess the most effective route for Tranexamic acid (TXA) administration 
among Intraarticular (IA), Intravenous (IV), and combined IA/IV for Total Knee Arthroplasty (TKA) 
surgeries.
Methods: A double-blinded clinical trial was run on 147 TKA candidates. Blood loss and hemoglobin (Hb) drop were 
evaluated using the Gross and Nadler formula in three matched case groups administered TXA during the TKA 
through IV, IA, or combined IA/IV route. Tourniquet was used on all operations for controlling intraoperative blood 
loss. No drainage catheter was used for the cases. 
Results: The combined group showed an average blood loss of 630±252 ml, which was significantly lower than 
that in the IV group (878±268 ml, P<0.01) and the IA group (774±288 ml, P=0.03). Furthermore, the mean Hb and 
hematocrit drop were significantly lower in the combined group, compared to the other two groups, 48 and 72 h 
postoperatively (P<0.05).
Conclusion: The combined IA/IV route had a 28% and 19% reduction of blood loss, compared to the IV or IA 
methods, respectively. Therefore, using TXA via the combined IA/IV route may be more effective for reducing 
perioperative blood loss following TKA surgery using a tourniquet without drain placement.
 Level of evidence: I

Keywords

Main Subjects


  1. McCalden R, Hart G, MacDonald S, Naudie D, Howard J, Bourne R. Clinical Results and Survivorship of the GENESIS II Total Knee Arthroplasty at a Minimum of 15 Years. J Arthroplasty. 2017; 32(7):2161-2166. doi:10.1016/j.arth.2017.02.006.
  2. Maradit Kremers H, Larson D, Crowson C, et al. Prevalence of Total Hip and Knee Replacement in the United States. J Bone Joint Surg Am.2015; 97(17):1386-97. doi:10.2106/JBJS.N.01141.
  3. Singh J, Yu S, Chen L, Cleveland J. Rates of Total Joint Replacement in the United States: Future Projections to 2020–2040 Using the National Inpatient Sample. J Rheumatol. 2019; 46(9):1134-1140. doi:10.3899/jrheum.170990.
  4. Sehat K, Evans R, Newman J. Hidden blood loss following hip and knee arthroplasty: Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br. 2004; 86(4):561-5. doi:10.1302/0301-620X.86B4.14508.
  5. Drain N, Gobao V, Bertolini D, et al. Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty. J Arthroplasty 2020; 35(6S):S201-S206. doi:10.1016/j.arth.2020.02.047.
  6. Poeran J, Rasul R, Suzuki S, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: Retrospective analysis of effectiveness and safety. BMJ. 2014; 349:g4829. doi:10.1136/bmj.g4829.
  7. Fillingham Y, Ramkumar D, Jevsevar D, et al. Tranexamic acid in total joint arthroplasty: the endorsed clinical practice guides of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. Reg Anesth Pain Med. 2019;44(1):7-111. doi:10.1136/rapm-2018-000024.
  8. Zhang Y-M, Yang B, Sun X-D, Zhang Z. Combined intravenous and intra-articular tranexamic acid administration in total knee arthroplasty for preventing blood loss and hyperfibrinolysis: A randomized controlled trial. Medicine (Baltimore). 2019; 98(7):e14458. doi:10.1097/MD.0000000000014458.
  9. Karampinas PK, Vlamis JA, Mpakalakos M, Papadelis EG, Adamidou-Lampropoulou K, Pneumatikos S. The combined intrarticular/intravenous administration of tranexamic acid in cemented total knee arthroplasty. Acta Orthopaedica ET Traumatologica Hellenica. 2018; 69(1).
  10. Lee S, Chong S, Balasubramanian D, Na Y, Kim T. What is the Ideal Route of Administration of Tranexamic Acid in TKA? A Randomized Controlled Trial. Clin Orthop Relat Res. 2017; 475(8):1987-1996.doi:10.1007/s11999-017-5311-z.
  11. Cals J, Amelsvoort L, Kotz D, Spigt M. CONSORT 2010 Statement-unfinished update? J Clin Epidemiol. 2011; 64(6):579-82. doi:10.1016/j.jclinepi.2010.10.007.
  12. Modi S, Deisler R, Gozel K, et al. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016;11:24. doi:10.1186/s13017-016-0078-1.
  13. Gross J. Estimating allowable blood loss: Corrected for dilution. Anesthesiology. 1983; 58(3):277-80. doi: 10.1097/00000542-198303000-00016.
  14. Nadler S, Hidalgo J, Bloch T. Prediction of blood volume in normal human adults. Surgery. 1962; 51(2):224-32.
  15. Sarzaeem M, Razi M, Kazemian G, Moghaddam M, Manafi A, Karimi M. Comparing Efficacy of Three Methods of Tranexamic Acid Administration in Reducing Hemoglobin Drop Following Total Knee Arthroplasty. J Arthroplasty. 2014; 29(8):1521-4.doi:10.1016/j.arth.2014.02.031.
  16. Iseki T, Tsukada S, Wakui M, Yoshiya S. Intravenous tranexamic acid only versus combined intravenous and intra-articular tranexamic acid for perioperative blood loss in patients undergoing total knee arthroplasty. Eur J Orthop Surg Traumatol. 2018; 28(7):1397-1402.doi:10.1007/s00590-018-2210-2.
  17. Yuan X, Wang J, Wang Q, Zhang X. Synergistic effects of intravenous and intra-articular tranexamic acid on reducing hemoglobin loss in revision total knee arthroplasty: a prospective, randomized, controlled study. Transfusion.2018; 58(4):982-988.doi:10.1111/trf.14477.
  18. Skovgaard Nielsen C, Jans Ø, Ørsnes T, Foss N, Troelsen A, Husted H. Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial. J Bone Joint Surg Am. 2016; 98(10):835-41. doi:10.2106/JBJS.15.00810.
  19. Meshram P, Palanisamy J, Seo J, Lee J, Kim T. Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial. Clin Orthop Relat Res. 2020; 478(1):45-54. doi:10.1097/CORR.0000000000000942.
  20. Zhou Q, Zhou Y, Wu H, et al. Changes of Hemoglobin and Hematocrit in Elderly Patients Receiving Lower Joint Arthroplasty without Allogeneic Blood Transfusion. Chin Med J (Engl). 2015; 128(1):75-8. doi:10.4103/0366-6999.147817.
  21. Lei Y, Xie J, Huang Q, Huang W, Pei F. Additional benefits of multiple-dose tranexamic acid to anti-fibrinolysis and anti-inflammation in total knee arthroplasty: a randomized controlled trial. Arch Orthop Trauma Surg.2020; 140(8):1087-1095.doi:10.1007/s00402-020-03442-2.
  22. Tsukada S, Wakui MD. Combined Intravenous and Intra-Articular Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty without Tourniquet Use. JB JS Open Access. 2017; 2(2):e0002. doi:10.2106/JBJS.OA.17.00002.
  23. Tsukada S, Kurosaka K, Nishino M, Maeda T, Hirasawa N, Matsue Y. Intraoperative Intravenous and Intra-Articular Plus Postoperative Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Placebo-Controlled Randomized Controlled Trial. J Bone Joint Surg Am.2020; 102(8):687-692. doi:10.2106/JBJS.19.01083.
  24. Lei Y, Xie J, Xu B, Xie X, Huang Q, Pei F. The efficacy and safety of multiple-dose intravenous tranexamic acid on blood loss following total knee arthroplasty: a randomized controlled trial. Int Orthop.2018; 42(3):499-505.doi:10.1007/s00264-017-3519-x.
  25. Mortazavi SMJ, Sattartabar B, Moharrami A, Kalantar sh. Intra-articular versus Intravenous Tranexamic Acid in total knee arthroplasty: a Randomized Clinical Trial study. Arch Bone Jt Surg. 2020; 8(3):355-362.doi:10.22038/abjs.2019.39080.2039.
  26. Schnettler T, Papillon N, Rees H. Use of a Tourniquet in Total Knee Arthroplasty Causes a Paradoxical Increase in Total Blood Loss. J Bone Joint Surg Am. 2017; 99(16):1331-1336. doi:10.2106/JBJS.16.00750.
  27. Maniar R, Pradhan P, Bhatnagar N, Maniar A, Bidwai R, Bindal P. Role of Suction Drain after Knee Arthroplasty in the Tranexamic Acid Era: A Randomized Controlled Study. Clin Orthop Surg. 2019; 11(1):73-81. doi:10.4055/cios.2019.11.1.73.
  28. Ye Xianhua, Chen Yinxiao, Lin Kang, Zheng Yanguo, ng JC. Clinical study of the optimal dose of intravenous tranexamic acid guided by thrombelastogram during the perioperative period of total knee arthroplasty. Int J Clin Exp Med. 2019; 12(6):6989-6998.
  29. Park J, Rasouli MR, Mortazavi S, Tokarski A, Maltenfort M, Parvizi J. Predictors of Perioperative Blood Loss in Total Joint Arthroplasty. J Bone Joint Surg Am. 2013; 95(19):1777-83.