The Efficacy and Safety of Combination of Intravenous and Topical Tranexamic Acid in Revision Hip Arthroplasty: A Randomized, Controlled Trial.

BACKGROUND: Revision total hip arthroplasty (THA) is associated with substantial blood loss and a high probability of blood transfusion in the perioperative period. This study aimed to evaluate the efficacy and safety of combination of intravenous (IV) and topical tranexamic acid (TXA) in revision THA. METHODS: Eighty-four consecutive patients undergoing revision THA were randomized into combined group and IV-TXA group. Patients in the combined group were given intravenously 15 mg/kg TXA as a preoperative, and topical TXA solution was applied at a concentration of 3 g TXA per 100-mL saline during the different procedure points. Patients in the IV-TXA group were given intravenously 15 mg/kg TXA alone. RESULTS: The mean total blood loss, drainage volume, and maximum hemoglobin drop were significantly lower in the combined group than the IV-TXA group (P < .001, P < .001, P < .001, respectively). Compared with the IV-TXA group, the amount of blood transfusions and number of blood transfusions required were decreased dramatically in the combined group (P = .027, P < .001, respectively). One deep vein thrombosis and 4 calf muscular vein thrombosis in the combined group and 3 calf muscular vein thrombosis in the IV-TXA were detected by the Doppler ultrasound. No pulmonary embolism was observed and no significant differences were found in other complications between the 2 groups. CONCLUSION: This study showed that combined administration of IV and topical TXA in revision THA can effectively decrease total blood loss and number of blood transfusions required without increasing the risk of deep vein thrombosis or/and pulmonary embolism compared with IV-TXA alone.

Insulin Dependence Increases the Risk of Complications and Death in Total Joint Arthroplasty: A Systematic Review and Meta-(Regression) Analysis.

OBJECTIVES: To investigate the proportion of insulin-dependent diabetes mellitus (IDDM) patients among diabetic patients undergoing total joint arthroplasty (TJA) and whether insulin dependence is associated with postoperative complications. METHODS: A systematic literature search was performed in EMBASE, PubMed, Ovid, Medline, the Cochrane Library, Web of Science, the China Science and Technology Journal Database, and China National Knowledge Infrastructure from the inception dates to 10 September 2019. Observational studies reporting adverse events with IDDM following TJA were included. Primary outcomes were cardiovascular complications, pulmonary complications, kidney complications, wound complications, infection, and other complications within 30 days of surgery. Secondary outcomes were the proportion of IDDM patients among diabetic patients undergoing TJA and its time trend. RESULTS: A total of 19 studies involving 85,689 participants were included. Among patients undergoing TJA, 26% of diabetic patients had IDDM. Compared with non-insulin-dependent diabetes (NIDDM), the incidences of cardiac arrest (risk ratio [RR], 2.346; 95% confidence interval [CI], 1.553 to 3.546), renal failure (relative risk [RR], 2.758; 95% CI, 1.830 to 4.156), deep incisional surgical site infection (RR, 1.968; 95% CI, 1.107 to 3.533), wound dehiscence (RR, 2.209; 95% CI, 1.830 to 4.156), and death (RR, 2.292; 95% CI, 1.568 to 3.349) were all significantly increased in IDDM. A significant time trend was witnessed for the prevalence of IDDM (P = 0.014). There was no statistical significance for organ/space surgical site infection, thrombotic events (deep venous thrombosis/ pulmonary embolism), and revision rates. CONCLUSION: Insulin-dependent diabetes is an independent high-risk factor for increased adverse outcomes relative to NIDDM, suggesting that hierarchical and optimal blood glucose management may contribute to reducing the adverse complications after surgery for these patients. In addition, because the risk of sepsis, deep wound infection, organ/space surgical site infection, urinary tract infection, renal insufficiency, and renal failure significantly increase after TJA in IDDM patients, more active postoperative antimicrobial prophylaxis may be needed on the premise of protecting renal function.

Comprehensive Comparison of Liposomal Bupivacaine with Femoral Nerve Block for Pain Control Following Total Knee Arthroplasty: An Updated Systematic Review and Meta-Analysis.

To compare the efficacy of liposomal bupivacaine (LB) and femoral nerve block following total knee arthroplasty, we conducted this systematic review and meta-analysis. 11 trials with 2,908 patients were included in this study. The pooled data demonstrated that total morphine consumption equivalents during the hospital stay was significantly increased in FNB group. In addition, LB has significantly better outcome in view of the postoperative functional recovery, such as the odds of fall, the incidences of straight leg rise (SLR), the number of patients who can walk independently in the day of surgery,the ambulation distance at POD1, the number of patients discharged at POD1. Consistent with the faster functional recovery, liposomal bupivacaine shortens the length of hospital stay. However, there was no significant difference between LB and FNB in terms of Visual Analogue Score (VAS) during the hospital stay. All in all, liposomal bupivacaine has significantly better outcome in view of the postoperative functional recovery and the length of hospital stay compared with femoral nerve block following the total knee arthroplasty.

Tranexamic Acid Plus Low-dose Epinephrine Reduces Blood Loss in Total Knee Arthroplasty: A Systematic Review and Meta-analysis.

The present study assessed the effectiveness of the combined administration of tranexamic acid (TXA) plus low-dose epinephrine in primary total knee arthroplasty (TKA). We searched the following Chinese electronic databases: China National Knowledge Infrastructure and WanFang Data. We also searched the following English electronic databases: PubMed, Embase, Web of Science, and Central Register of Controlled Trials. To search for additional eligible studies, we also used Google's search engine. All randomized controlled trials (RCT) comparing TXA plus low-dose epinephrine (Combined group) and TXA alone in TKA were systematically searched. The primary outcomes were total blood loss, hidden blood loss, the requirement for transfusion, maximum hemoglobin (Hb) drop, and deep venous thrombosis (DVT). Drainage volume, operation time, length of stay, hospital for special surgery (HSS) score, and range of motion (ROM) were considered as secondary outcomes. Subgroup analyses were performed to assess the benefits of using a tourniquet and the application routes of topical or intravenous TXA between the two groups. Statistical analysis was assessed using RevMan 5.3 software. Four independent RCT were included involving 426 patients, with 213 patients in the Combined group and 213 patients in the TXA alone group. In the Combined group there was significant reduction in total blood loss (MD, 204.70; 95% CI, -302.76 to -106.63; P < 0.0001), hidden blood loss (MD, 185.63; 95% CI, -227.56 to -143.71; P < 0.00001), drainage volume (MD, 93.49; 95% CI, -117.24 to -69.74; P < 0.00001), and maximum Hb drop (MD, 5.33, 95% CI, -6.75 to -3.91; P < 0.00001). No statistical differences were found postoperatively in terms of the requirement for transfusion (risk ratio, 0.52; 95% CI, 0.26-1.04; P = 0.06), operation time (MD, 0.85; 95% CI, -2.62 to 4.31; P = 0.63), length of stay (MD, -0.02; 95% CI, -0.52 to 0.47; P = 0.93), HSS score (MD, 0.78; 95% CI, -0.36 to 1.92; P = 0.18), and ROM (MD, 1.40; 95% CI, -1.01 to 3.81; P = 0.26), and not increasing the risk of DVT (risk ratio, 1.00; 95% CI, 0.33 to 3.02; P = 1.00) in the two groups. This meta-analysis demonstrated that the administration of tranexamic acid plus low-dose epinephrine is a safe and efficacious treatment to reduce total blood loss, hidden blood loss, drainage volume, and maximum Hb drop in primary TKA, without increasing the risk of DVT in primary THA.

Combination of erythropoietin and tranexamic acid in bilateral simultaneous total hip arthroplasty: a randomised, controlled trial.

INTRODUCTION: This study aimed to evaluate whether the combination of erythropoietin (EPO) and tranexamic acid (TXA) exerted any additional benefits on the number of blood transfusions required and haematological parameters compared with TXA alone following primary bilateral simultaneous total hip arthroplasty. MATERIALS AND METHODS: We conducted a single-centre, prospective, randomised, and controlled trial at our hospital. Group EPO + TXA (n = 30) received daily subcutaneous injections EPO (10,000 IU) on preoperative days 1-4 and postoperative days 1-3. Additionally, these patients were administered TXA (15 mg/kg) 10 min prior to the incision. Group TXA (n = 32) received only TXA (15 mg/kg) 10 min prior to the incision. The primary outcomes were the haematological parameters and number of blood transfusions required. The secondary outcomes were total blood loss, drainage volume, and postoperative complications. RESULTS: The total amount of blood transfusion and mean blood transfusion per patient was lower in group EPO + TXA than in group TXA (p = 0.039, p = 0.023; respectively). In the postoperative period, patients in group EPO + TXA had higher haematological parameters (haemoglobin, haematocrit, and reticulocyte count) than patients in group TXA. No significant differences were found in total blood loss, drainage volume, and DVT or PE between the 2 groups. CONCLUSIONS: This study showed that administrating EPO + TXA in combination can increase haematological parameters and reduce the need for blood transfusion without increasing the risk of DVT or PE compared with TXA alone.