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Use of combined IV, intra-articular TXA linked with reduced blood loss in TKA
This may be the first study of TXA injection in TKA where tourniquets, drains were not used and mobilization occurred immediately after surgery.
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Patients who underwent total knee arthroplasty and received both IV and intra-articular administration of tranexamic acid had a clinically relevant 37% reduction in blood loss at 24 hours and 48 hours postoperatively compared with patients who received only intravenous administration of tranexamic acid, according to results of a randomized, double-blind placebo-controlled study of 60 patients from Denmark.
The study, which was published in the Journal of Bone and Joint Surgery, was the first of its kind to study the addition of intra-articular injection of tranexamic acid (TXA) with contemporary total knee arthroplasty (TKA) done without a tourniquet or drain and with very early mobilization on the day of surgery, according to Henrik Husted, MD, DMSc, PhD, study coauthor and head of orthopaedics at Copenhagen University Hospital Hvidore in Copenhagen, Denmark.
The 60 patients studied were randomized so that 30 patients had 3 g TXA diluted in 100 mL saline injected through the capsule into the knee joint after it was surgically closed and 30 patients had placebo treatment with 100 mL saline alone injected into the closed capsule. This was, in both groups, in addition to 1 g TXA administered intravenously at the start of the surgery.
After the injections, surgeons flexed patients’ knees to distribute the injected material throughout the joint.
Single intra-articular injection
“This method is simple. It is efficient. It is cheap and it will give you well up to 37% extra reduction in the blood loss compared to just giving a single IV dose [of TXA],” Husted told Orthopaedics Today Europe.
Investigators used the Gross formula to calculate mean blood loss at 24 hours and 2 days postoperatively. Both groups of patients were similar based on their baseline characteristics. They all underwent TKA with cemented cruciate-retaining knee prostheses.
At 24 hours, the mean blood loss was 466 mL in patients who were administered TXA both intravenously and intra-articularly and 743 mL in patients who were administered intravenous TXA only and had a placebo injection. After 2 days, the mean blood loss for patients given TXA intravenously and intra-articularly was 644 mL and for patients in the placebo group it was 1,017 mL. Three patients, two in the active injection group and one in the placebo group, were lost to follow-up for the 2-day blood loss analysis.
No complications reported
Investigators noted after 90 days postoperatively, there were no thromboembolic complications in either group. One patient in the placebo group received red blood cells postoperatively due to low Hb levels on a blood test. The injections added no extra time to the surgeries, according to Husted.
“It takes less than 1 minute to do the injection,” he said.
Being assessed in revision TKA
Husted said he sees no contraindications to injected TXA from his experience or what is reported in the systematic reviews and meta-analyses published on this topic.
“Of course, this study was not powered regarding safety,” he added.
Husted and colleagues are further investigating TXA injection added to TXA intravenously.
“We are looking at doing it in revision knees where you may have even more blood loss,” he said, noting still more needs to be understood about how and why TXA injections work.
“This methodology is applicable to both hips and knees, revisions and maybe also other joints. It could be the same for hip fractures or ankle fractures — anywhere you have a closed joint cavity,” Husted said. – by Monica Jaramillo and Susan M. Rapp
- Reference:
- Nielsen CS, et al. J Bone Joint Surg Am. 2016;doi.org/10.2106/JBJS.15.00810.
- For more information:
- Henrik Husted, MD, DMSc, PhD, can be reached at Hvidovre University Hospital, 2650 Hvidovre, Denmark; e-mail: henrikhusted@dadlnet.dk.
Disclosure: Husted reports he is a paid consultant to Zimmer Biomet for Rapid Recovery.
Perspective
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Ajay Malviya, FRCS T&O, MSc, MRCSEd, MS T&O
The authors should be commended for setting up this scientifically sound study that has demonstrated an additional benefit of combining 1 g of IV tranexamic acid (TXA) with local infiltration during knee replacement. It is difficult to know if the difference in blood loss was because of the dose effect or truly because of the local injection. When we, at Northumbria NHS Healthcare Trust, increased the dose of IV TXA from 15 mg/kg (1g IV) to 30 mg/kg (2 g IV), we noted our transfusion rate after hip and knee replacement decreased by almost 30% without any thromboembolic complications. Regardless, the authors propose a measure that can be easily adopted in practice.
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