Total blood loss and early clinical outcomes under different tranexamic acid regimes in total knee arthroplasty.

BACKGROUND: Many different regimes of intravenous and local tranexamic acid (TXA) reduce total blood loss (TBL) in patients undergoing total knee arthroplasty (TKA). However, the most effective TXA regime in reducing blood loss might not be most beneficial for the patient. The aim of the present study was to investigate the effect of commonly used TXA regimes on blood loss and on early clinical outcomes. METHODS: We performed this monocentric retrospective study in patients undergoing primary TKA. Primary outcome was the estimated TBL. Secondary outcomes were the rates of adverse events (AE) as well as the range of motion (ROM), mobility and pain intensity during the first three physiotherapy sessions (PTS). RESULTS: We analysed the data of 1250 TKAs. 5 different TXA regimes were applied. TBL (mean ± SE) was 953 ± 64 ml (2xiv), 999 ± 19 ml (2xiv + 1xlocal), 1075 ± 19 ml (1xiv + 1xlocal), 1191 ± 39 ml (1xlocal) and 1241 ± 48 ml (1xiv) (p < 0.01). In the linear regression model for TBL a lower number of TXA applications was a predictor for increased blood loss (p < 0.01). AE rates were lowest under 2xiv (0%) and 2xiv + 1xlocal (4.8%). Highest mobility and lowest pain intensity were observed under 1x iv and 2x iv. The largest portions of fully mobile patients on day three were observed under 1xiv (100%), 2xiv (100%) and 2xiv + 1local TXA (86.9%). CONCLUSION: Our results suggest that multiple applications of TXA are more effective in decreasing blood loss than excessive dosing of TXA. Interestingly, local use of TXA might be associated with higher pain intensity and decreased mobility on the first days after surgery.

Hemostatic effect and safety evaluation of oxidized regenerated cellulose in total knee arthroplasty- a randomized controlledtrial.

BACKGROUND: Oxidized regenerated cellulose (ORC) is a type of biodegradable hemostatic material, which has been widely used in the field of surgery. However, its hemostatic effect in patients undergoing total knee arthroplasty (TKA) is uncertain. Accordingly, this study investigated the effectiveness and safety of ORC in patients receiving TKA. METHODS: Seventy patients undergoing unilateral TKA were randomized into blank control group and ORC (2 pieces of ORC placed in the joint cavity) groups. Then, the two groups were compared for primary (perioperative blood loss [total blood loss, intraoperative blood loss, and hidden blood loss] and hemoglobin drop values) and secondary (coagulation indicators, inflammatory indicators,operation time, and complication rates) outcomes. RESULTS: The total blood loss in the ORC group was 902.32 ± 307.82 mL, which was statistically significantly lower than that in the control group (1052.25 ± 308.44 mL) (P < 0.05). Postoperative hidden blood loss was also statistically markedly lower in the ORC group (801.61 ± 298.80 mL) than in the control group (949.96 ± 297.59 mL) (P < 0.05). There was no significant difference between the two groups in terms of coagulation indicators, inflammatory indicators, operation time, and complication rates. CONCLUSION: In conclusion, our prospective RCT study proved that regenerated oxidized cellulose can be used safely in vivo and can effectively reduce postoperative blood loss in patients, which is a potential method for preventing blood loss after TKA. TRIAL REGISTRATION: This prospective RCT was reviewed and approved by the Ethics Committee of Honghui Hospital of Xi'an Jiaotong University (No: 202,211,007) and was designed and conducted according to the rules of the Declaration of Helsinki. Written informed consent was obtained from patients or their legal guardians.

Comparison of the total and hidden blood loss in patients undergoing single-level open and unilateral biportal endoscopic transforaminal lumbar interbody fusion: a retrospective case control study.

PURPOSE: This study aimed to compare total blood loss (TBL) and hidden blood loss (HBL) in patients undergoing single-level open transforaminal lumbar interbody fusion (O-TLIF) and unilateral biportal endoscopic transforaminal lumbar interbody fusion (ULIF). METHODS: A total of 53 patients who underwent ULIF and 53 patients who underwent O-TLIF from March 2020 to July 2022 were retrospectively reviewed. The Nadler's formula was employed to estimate the patient's blood volume (PBV), Gross's formula to estimate TBL, and Sehat's formula to estimate HBL. The obtained data were then analyzed with independent t test, chi-squared test, and analysis of covariance. RESULTS: TBL and measured blood loss (MBL) in ULIF group (326.86 ± 223.45 ml, 99.00 ± 72.81 ml) was significantly lower than O-TLIF group (427.97 ± 280.52 ml, 270.66 ± 102.34 ml). Nevertheless, the HBL in ULIF group was higher than that in O-TLIF group (227.86 ± 221.75 ml vs 157.31 ± 268.08 ml), however this was not statistically significant (p = 0.143). The HBL was 69.71 ± 23.72% of TBL in ULIF group and 36.76 ± 18.79% of TBL in O-TLIF group. Patients in ULIF group had lower TBL and MBL, shorter duration of drainage, lower postoperative anemia, and shorter postoperative hospital stay compared to those in O-TLIF group. CONCLUSIONS: Perioperative HBL should not be neglected in patients undergoing ULIF or O-TILF, as it accounts for a large percentage of TBL in both groups. ULIF is associated with lower TBL and MBL, postoperative anemia, shorter postoperative hospital stays compared with O-TLIF.

Comparison of hidden blood loss and clinical efficacy of percutaneous endoscopic transforaminal lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion.

PURPOSE: Hidden blood loss (HBL) is a growing area of interest for spinal surgeons. Simultaneously, spine surgeons' pursuit of minimally invasive spine surgery has never ceased, as evidenced by the increasing number of articles comparing percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) and minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF). However, there has been no comparison of HBL between Endo-TLIF and Mis-TLIF. This study aimed to compare HBL, visible blood loss (VBL), and total blood loss (TBL) following Endo-TLIF and Mis-TLIF and evaluate the clinical significance of these procedures. METHODS: Between October 2017 and October 2019, 370 patients underwent lumbar interbody fusion at our institution and were followed up for at least 24 months. Our study included 41 Endo-TLIF and 43 Mis-TLIF cases. We recorded each patient's age, height, weight, and haematocrit and calculated the TBL, which was used to indirectly obtain the HBL. Additionally, we compared the clinical outcomes of these two groups, including visual analogue scores for the lumbar spine and leg (VAS-Back; VAS-Leg), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, disease type, operative segment, and intervertebral fusion and complication rates. RESULTS: Endo-TLIF had significantly lower HBL, VBL, and TBL values than Mis-TLIF (P < 0.05 for all). Although Endo-TLIF contained significantly less HBL than Mis-TLIF, the HBL to TBL ratio was statistically greater in Endo-TLIF (91%) than in Mis-TLIF (87%). Concerning clinical outcomes, VAS-Back, VAS-Leg, ODI, JOA, and Endo-TLIF demonstrated greater improvement rates than Mis-TLIF one week post-operatively. However, at the final follow-up, VAS-Back, VAS-Leg, ODI, and JOA scores all demonstrated a trend toward sustained improvement, with no statistically significant between-procedure difference. There were no statistically significant between-procedure differences in disease type, surgical segment, and complication or fusion rates. CONCLUSION: Endo-TLIF significantly reduced HBL, VBL, and TBL compared to Mis-TLIF and improved short-term clinical outcomes; however, long-term clinical outcomes and fusion rates remained comparable between the two groups, as did the incidence of peri-operative complications.

Assessment of perioperative total blood loss during total ankle arthroplasty.

BACKGROUND: Although many authors have discussed total blood loss after arthroplasty of the knee, hip, and shoulder, reports on perioperative blood loss after total ankle arthroplasty (TAA) are rare. The purpose of this study was to assess total blood loss after TAA and to identify correlated factors. METHODS: A total of 103 cases (99 patients) of TAA for end-stage ankle osteoarthritis were enrolled in this study. Perioperative total blood loss was divided into intraoperative and postoperative blood loss. The patient-related variables evaluated for total blood loss were age, sex, body mass index, American Society of Anesthesiologists Classification score, comorbidities, history of previous ankle surgery, preoperative use of anticoagulants, platelet count and prothrombin time/international normalized ratio. Operation-related variables including type of anesthesia, operation time, TAA implant, and procedures performed in addition to TAA (if any) were evaluated to analyze correlations with total blood loss. In addition, the rate of transfusions after surgery was identified, and risk factors for transfusion were statistically analyzed. RESULTS: The total blood loss was mean 795.5±351.1mL, which included 462.2±248.5mL of intraoperative blood loss and 333.2±228.6mL of postoperative blood loss. Sex, TAA implant, and additional bony procedures performed along with TAA were significantly correlated with total blood loss (p=0.039, 0.024, 0.024, respectively) but the other variables were not significant (p>0.05). Transfusions were administered for 4 cases (3.8%) but no risk factors for transfusion could be identified. CONCLUSION: The total blood loss after TAA was 795.5mL and the rate of transfusions was 3.8%. This study demonstrated that male sex, use of TAA implants with a larger cutting surface, and bony procedures performed in addition to TAA were associated with an increase in total blood loss after TAA. The findings of this study will help surgeons to better predict blood loss and make optimal surgical plans accordingly. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Effects of tourniquet use on clinical outcomes and cement penetration in TKA when tranexamic acid administrated: a randomized controlled trial.

BACKGROUND: The role of a tourniquet is still controversial for patients undergoing total knee arthroplasty (TKA). Our current study was performed to determine whether the nonuse of the tourniquet combine with tranexamic acid (TXA) application in TKA patients with end-stage osteoarthritis would accelerate the perioperative recovery rate and provide enough cement mantle thickness for implant fixation. METHODS: In this prospective, randomized controlled trial, 150 end-stage knee osteoarthritis patients receiving TKA were divided into three groups: group A (tourniquet group), group B (non-tourniquet group), and group C (tourniquet in cementation group). All enrolled patients received 3 g of intravenous TXA and 1 g topical TXA. The primary outcomes included blood loss variables and transfusion values. The secondary outcomes included VAS pain score, inflammatory factors level, range of motion, HSS score, postoperative hospital stay, and complication. Furthermore, by using a digital linear tomosynthesis technique, tibial baseplate bone cement mantle thickness was measured in four zones based on the knee society scoring system. RESULTS: No significant difference was found among the three groups with regards to total blood loss, transfusion, and complication. However, patients in group B showed lower inflammatory factors levels, shorter length of hospital stay, better range of motion, and lower postoperative pain. No significant difference was found among the three groups in four zones in terms of bone cement mantle thickness. CONCLUSIONS: For end-stage knee osteoarthritis patients, the absence of tourniquet did not appear to affect blood loss and cement penetration in TKA patients. Furthermore, less inflammation reaction and better knee function can be achieved without a tourniquet. We recommend no longer use a tourniquet in primary TKA for patients with end-stage osteoarthritis when TXA is administrated. TRIAL REGISTRATION: ChiCTR-INR-16009026 . LEVEL OF EVIDENCE: Therapeutic Level I.

Effectiveness of different doses and routes of administration of tranexamic acid for total hip replacement.

PURPOSE: The aim of the study is to show the therapeutic efficacy, safety, and cost-benefit of using tranexamic acid (TXA), as well as the superiority of the route of administration and amount of dose in primary cementless total hip replacement (THR). METHODS: In this prospective, randomized, double-blind study, we divided 200 patients into five groups of 40 patients each. The placebo group did not receive TXA. Three groups received 2 g TXA each (intravenous, topical, and combined intravenous + topical), while the fifth, combined + group, received 4 g TXA. Total blood loss was calculated, number of transfusions and thromboembolic vascular incidents were monitored, and a cost-benefit analysis of the use of TXA was performed. RESULTS: Regardless of the route of administration, TXA statistically significantly reduced total blood loss (p = 0.000) and the need for transfusion (p = 0.000) compared with placebo. Total blood loss and the need for allogenic blood transfusion were statistically significantly reduced in the combined + group compared with placebo, and also compared with all other groups. Post-operative thromboembolic vascular incidents were not reported. The cost-benefit of using TXA in THR is associated with reduction of transfusion costs. CONCLUSIONS: None of the TXA administration routes are superior to others, but multiple doses could statistically significantly reduce blood loss and transfusion requirements, which should be the subject of future researches.

Factors affecting blood loss and blood transfusion in patients with proximal humeral fractures.

BACKGROUND: The aim of this study was to determine the amount of blood loss and the rate of blood transfusion in patients receiving surgery for proximal humeral fractures depending on the treatment and fracture classification. Moreover, factors associated with blood loss and blood transfusion were analyzed. METHODS: The study included 420 patients who had received surgery for proximal humeral fractures. Data from medical records were collected retrospectively. The calculated blood loss and the transfusion rate were analyzed depending on the type of surgery (plate fixation, arthroplasty, and others) or the fracture classification (2-, 3-, and 4-part fractures). The extent of blood loss and the need for transfusion were correlated with potential risk factors. A score to estimate the probability of blood transfusion was developed. RESULTS: Average blood loss was 284 mL, and the transfusion rate was 14.5% for all proximal humeral fractures. Shoulder arthroplasty was associated with higher blood loss (353 mL, P < .01) and a higher blood transfusion rate (27.3%, P < .01) than plate fixation (263 mL and 10.9%, respectively). The fracture classification had no effect on either factor. Significant risk factors for blood loss were male sex, body mass index, surgery time, time until surgery, and vitamin K antagonists. Age, blood loss, American Society of Anesthesiologists score greater than 2, vitamin K antagonists, coronary artery disease (CAD), peripheral artery disease (PAD), and renal disease were associated with a higher transfusion rate. CONCLUSION: Blood loss could be affected by a shorter surgery time and by choosing an adequate time until surgery. The consideration of risk factors and the use of a transfusion risk score allow more elaborate ordering of cross-matched blood units and can decrease institutional costs.

Differences in total blood loss and transfusion rate between different indications for shoulder arthroplasty.

PURPOSE: In this study, the total blood loss, transfusion rate and number of transfused blood units in patients with different indications for shoulder arthroplasty: primary, fracture and secondary were compared. Risk factors for bleeding and transfusion were analysed. METHODS: Medical records and the database of the institution's blood bank from 527 patients that received shoulder arthroplasty were analysed retrospectively. This study included 419 patients that were divided in three different groups: primary (n = 278), fracture (n = 110) and secondary (following prior osteosynthesis; n = 31) shoulder arthroplasty. The demographic and clinical data were collected. The total blood loss (TBL) was calculated and transfusions recorded. RESULTS: The transfusion rate and mean amount of transfused blood units (BU) were higher in fracture (32.7% and 0.69BU, p < 0.01) and secondary arthroplasty (35.5% and 0.97BU, p < 0.01) than in primary arthroplasty (12.6% and 0.28BU). The overall transfusion rate was 19.6% at a mean TBL of 370 ml. However, patients with primary arthroplasty experienced significantly higher total blood loss than those after fracture arthroplasty (p < 0.01). Longer surgery time and male sex are significant risk factors for elevated blood loss. The pre-operative use of vitamin K antagonist, cemented arthroplasty, high BMI, coronary heart disease and ASA score > 2 are relevant risk factors for blood transfusion. CONCLUSION: The most important susceptible factor that affects the TBL is the surgery time. Transfusion rates are higher in patients with fracture arthroplasty than after primary arthroplasty.

Bleeding in primary shoulder arthroplasty.

INTRODUCTION: The aim of this investigation was to analyse "total blood loss" (TBL), "blood transfusion rate" (BT) and the "amount of transfused blood units" (BU) between the different primary shoulder arthroplasty (SA) types: reverse, anatomical and stemless. Only primary SA was included. Further goal was to identify risk factors for TBL, amount of BU and BT rate. METHODS: A retrospective charts analysis of patients who received primary SA for degenerative shoulder pathology in our institution between 2004 and 2016 was performed. The demographic data, co-morbidities, haemoglobin and hematocrit level, BT rate, amount of transfused BU etc. were collected. TBL was estimated. Linear regression, log-linear poisson regression and logistic regression were used to compare the outcomes TBL, amount of transfused BU and BT rate, respectively, between different prosthesis types. RESULTS: Of 278 patients included in this study 209 received reverse, 57 anatomical and 12 stemless SA. Mean TBL was 392.7 ml in reverse, 394.6 ml in anatomical and 298.3 ml in stemless SA. The BT rate and mean amount of BU were, respectively, 14.4% and 0.32 in reverse and 8.77% and 0.23 in anatomical SA. None of the patients with stemless arthroplasty received BT. Significant risk factors for elevated TBL are operation time, higher BMI, male sex. Significant risk parameters for BT and higher amount of transfused BU are low BMI, cemented arthroplasty, coronary heart disease, ASA score > 2 and previous therapy with vitamin K antagonists. CONCLUSION: Although there were little differences between the blood transfusion rates in reverse vs. anatomical arthroplasty, there was no difference in total blood loss between these different prosthesis types. None of the patients with stemless arthroplasty received blood transfusion. There are various risk factors affecting total blood loss and blood transfusion rate. However, risk parameters influencing blood transfusion may be different to them affecting total blood loss.

Intra-articular Application is More Effective Than Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial.

BACKGROUND: The optimal administration route of tranexamic acid (TXA) in total knee arthroplasty (TKA), and the effect of TXA on hidden blood loss and total blood loss are undetermined. The purpose of this study was to compare the effectiveness of intravenous versus intra-articular application of tranexamic acid in patients undergoing knee arthroplasty. METHODS: A total of 150 patients undergoing primary unilateral total knee arthroplasty were randomly distributed to 3 groups (IV, intra-articular, and control group; each 50 patients) and administrated TXA (1 g IV and 50 mL intra-articular saline, 1 g intra-articularly and 50 mL intra-articular saline, and 0 g and 50 mL intra-articular saline, respectively). The amount of total and hidden blood loss (HBL), drainage, transfusion, changes in hemoglobin levels, and complications were recorded. RESULTS: Intra-articular use of TXA reduced more total blood loss (P = .011) and reduced more total 48 hours drainage volume than IV use of TXA (P < .001). Two patients received transfusion in IV and control group. No deep venous thrombosis or other severe complications had occurred. The HBL volume had no significant difference among the control, IV, and intra-articular groups (708.6 ± 308.2, 651.7 ± 302.9, and 625.2 ± 252.1 mL, respectively; which was 65.6%, 70.8%, and 81.1% of the total loss). CONCLUSION: Intra-articular administration of TXA significantly reduced total blood loss and drainage volume to a greater degree than IV injection in total knee arthroplasty without reduction of HBL.

Blood-Sparing Efficacy of Oral Tranexamic Acid in Primary Total Hip Arthroplasty.

BACKGROUND: Tranexamic acid (TXA) has been shown to be effective in reducing blood loss, hemoglobin drop, and blood transfusion in primary total hip arthroplasty. Most studies used intravenous form or topical form. This study was to assess the blood-sparing efficacy and safety of oral TXA in total hip arthroplasty. METHODS: Patients with primary total hip arthroplasty from 2012 to 2015 were recruited. Trial group with 1 gm of oral TXA 2 hours preoperatively, and 6 hours and 12 hours postoperatively was compared with the control group without drug. Outcome measures were intraoperative blood loss, drain output, observed total blood loss, actual total blood loss, hidden blood loss, hemoglobin drop, blood transfusion requirement, thromboembolic complications, cerebrovascular or cardiovascular complications, and mortality. RESULTS: After exclusion, 108 patients were included-54 in trial group and 54 in control group. There was no significant difference in the baseline characteristics. The trial group had significantly higher postoperative hemoglobin (10.3 vs 9.4 g/dL), lower hemoglobin drop (3.0 vs 4.1 g/dL), lower hidden blood loss (149 vs 354 mL), and lower actual total blood loss (847 vs 1096 mL). There was no significant difference in thromboembolic complications or mortality. There was also no periprosthetic infection or drug allergy. CONCLUSION: Oral TXA is effective in blood sparing in terms of reduction in hemoglobin drop, hidden blood loss, and actual total blood loss. It is safe and is an alternative to the intravenous or topical form.

The Efficacy of Combined Use of Rivaroxaban and Tranexamic Acid on Blood Conservation in Minimally Invasive Total Knee Arthroplasty a Double-Blind Randomized, Controlled Trial.

BACKGROUND: Tranexamic acid (TXA) was reportedly to decrease postoperative blood loss after standard total knee arthroplasty (TKA). However, the blood-conservation effect of TXA in minimally invasive TKA, in particular, receiving a direct oral anticoagulant was unclear. The aim of the study was to investigate the efficacy of combined use of TXA and rivaroxaban on postoperative blood loss in primary minimally invasive TKA. METHODS: In a prospective, randomized, controlled trial, 198 patients were assigned to placebo (98 patients, normal saline injection) and study group (100 patients, 1g TXA intraoperative injection) during primary unilateral minimally invasive TKA. All patients received rivaroxaban 10 mg each day for 14 doses postoperatively. Total blood loss was calculated from the maximum hemoglobin drop after surgery plus amount of transfusion. The transfusion rate and wound complications were recorded in all patients. Deep-vein thrombosis was detected by ascending venography of the leg 15 days postoperatively. RESULTS: The mean total blood loss was lower in the study group (1020 mL [95% confidence interval, 960-1080 mL]) compared with placebo (1202 mL [95% confidence interval, 1137-1268 mL]) (P < .001). The transfusion rate was lower in the study group compared with placebo (1% vs 8.2%, P = .018). Postoperative wound hematoma and ecchymosis were higher in placebo than the study group (P = .003). There was no symptomatic deep-vein thrombosis or pulmonary embolism in either group. CONCLUSION: Systemic administration of TXA can effectively reduce the postoperative blood loss which results in lower rate of transfusion requirement and wound hematoma in minimally invasive TKA patients when rivaroxaban is used for thromboprophylaxis. Rivaroxaban has a high rate of bleeding complications when used alone in TKA patients.

Drain use in total knee arthroplasty is neither associated with a greater transfusion rate nor a longer hospital stay.

PURPOSE: In recent years, the exclusion of a drain in total knee arthroplasty (TKA) is gaining popularity. This retrospective study aims to investigate a tertiary hospital's experience with the use of a drain in TKA. The authors hypothesise that the use of a drain will: (1) increase the peri-operative total blood loss (TBL) and transfusion rate; (2) increase the length of hospital stay (LOS); (3) reduce the 30-day readmission rate and incidence of additional surgical procedure performed. METHODS: Patients who underwent a unilateral primary TKA in 2012 were included. Seven surgeons performed 575 TKAs with the use of drains, while nine other surgeons performed 902 TKAs without the use of drains. The patients were prospectively followed-up for two years. Peri-operative TBL was calculated using the haemoglobin balance method. All patients followed the hospital's transfusion and post-operative rehabilitation protocol. RESULTS: There was a bigger drop in haemoglobin level by 0.5 g/dl (95 % CI, 0.4, 0.6) and greater TBL by 169 ml (95 % CI, 126, 181) in the drain group (both p < 0.001). However, the transfusion rate was 37/575 (6.4 %) and 48/902 (5.3 %) in the drain and no drain groups respectively (p = 0.370), while the LOS was four (IQR, 4, 5) and four (IQR 3, 5) days respectively (p = 0.228). The 30-day readmission rate was 10/575 (1.7 %) in the drain group, compared with 26/902 (2.9 %) in the no-drain group (p = 0.165). The incidence of additional surgical procedure performed was 5/575 (0.9 %) in the drain group, compared with 15/902 (1.7 %) in the no-drain group (p = 0.198). CONCLUSIONS: Although the use of a drain in TKA is associated with greater peri-operative TBL, this additional amount of blood loss does not translate into an increased transfusion rate or a longer LOS. It also does not reduce the 30-day readmission rate and incidence of additional surgical procedure performed on the same knee.

Longtime soaking of high concentration tranexamic acid in total hip arthroplasty: A prospective randomized controlled trial in 224 patients.

OBJECTIVES: To evaluate the efficacy and safety of intra-articular Soaking of high concentration Tranexamic Acid (TXA) in total hip arthroplasty. METHODS: From March 2013 to March 2014, 224 patients who underwent unilateral primary THA in our hospital was enrolled in this randomized, prospective double-blinded study. The patients were allocated into two groups according to intra-articular solution received: Intra-articular soaking of TXA group, Control group (physiologic saline). The solution was injected from intermuscular space following fixation of the implants and closure of articular capsule, short external rotators. Total blood loss, total volume of drainage and transfusion were recorded. Postoperative deep vein thrombosis and other complications was also measured. RESULTS: The mean total blood loss was 730±296 ml in intra-articular soaking of TXA group compared with 1048±295ml in control group (P<0.05). The postoperative mean total volume of drainage was 93±50 mL in intra-articular soaking of TXA group versus 312±136 mL in control group.22 patients (19.8%, control) and 6 patients (5.3%, Intra-articular soaking of TXA) required transfusion (P=0.001). Postoperative deep vein thrombosis and other complications were no statistical significance between the two groups. CONCLUSIONS: Intra-articular soaking of high concentration TXA with 2-hour clamping drain can reduce the total blood loss and transfusion rates in primary THA without significant increase in postoperative thrombotic complications.

Dose Comparison of Flowable Gelatin Hemostatic Matrix for Bleeding Loss in Primary Total Knee Arthroplasty.

Introduction Intraoperative and postoperative bleeding in total knee arthroplasty (TKA) affects postoperative outcomes. Although the hemostatic effect of a flowable gelatin hemostatic matrix (FGHM) is known across several surgical fields, its effectiveness on TKA remains controversial. This study aimed to compare the amount of bleeding across three groups treated with different doses of FGHM in TKA. Methods Overall, 122 knee joints of patients who underwent unilateral primary TKA were included and divided into three groups according to FGHM dose: absence of FGHM (control group, N=48), administration of 5 mL of FGHM (5 mL group, N=46), and administration of 8 mL of FGHM (8 mL group, N=38). Total hemoglobin (Hb) loss, drain output, hidden blood loss (HBL), calculated total blood loss (TBL) on the first postoperative day (POD1) and one week postoperatively (POD7), postoperative flexion angle at one week and discharge, and incidence of postoperative deep venous thrombosis (DVT) were assessed. Results At POD1, the mean total Hb losses were 6.3±3.1g (control group), 5.5±3.3g (5 mL group), and 5.3±2.5g (8 mL group), with no significant differences. At POD7, the mean Hb losses were 9.1±4.6g (control), 8.7±3.6g (5 mL), and 8.3±4.0g (8 mL), also with no significant differences. Mean drain outputs and HBLs showed no significant differences among groups. While there was a decreasing trend in TBL with higher FGHM doses, it was not statistically significant at either POD1 or POD7. There were no statistically significant differences in the mean postoperative flexion angle at POD7 or discharge among the groups (99.7±12.6°, 95.7±12.5°, 98.3±13.8° at POD7; 115.9±9.7°, 113.8±9.6°, 116.6±9.2° at discharge). Of these, only one patient in the 8 mL group developed proximal DVT. Conclusion Despite a trend towards decreased bleeding with FGHM, no significant differences were found among the three groups. However, the clinical utility of this hemostatic agent for reducing blood loss after primary TKA remains still unclear.

Effect of Tranexamic Acid on Hidden Blood Loss in Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion: A Retrospective Study.

Purpose: Percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) has become one of the most popular minimally invasive surgeries today. However, the issue of hidden blood loss (HBL) in this surgery has received little attention. This study aims to examine the HBL in PE-TLIF surgery and the effect of tranexamic acid (TXA) on blood loss. Methods: In our research, We conducted a retrospective analysis of 300 patients who underwent PE-TLIF from September 2019 to August 2023. They were divided into 2 groups based on whether they received intravenous TXA injection before surgery. The variables compared included: demographic data, pre-and postoperative hemoglobin (HB), hematocrit (HCT), platelets (PLT), red blood cells (RBC), total blood loss (TBL), visible blood loss (VBL), HBL, operation time, postoperative hospital stay, inflammatory markers, coagulation parameters, and adverse events. Results: Regarding demographic characteristics, besides the operation time, no significant differences were observed between the two groups. Compared with the control group, the TXA group showed a significant reduction trend in TBL, HBL, and VBL (P < 0.05). On the first day after surgery, there were significant differences in prothrombin (PT), activated partial thromboplastin time (APTT), and D-dimer (D-D) levels between the two groups. Similarly, HCT also found similar results on the third day after surgery. No adverse events occurred in either group. Conclusion: Research has found that there is a significant amount of HBL in patients undergoing PE-TLIF. Intravenous injection of TXA can safely and effectively reduce perioperative HBL and VBL. Additionally, compared to the control group, the TXA group shows a significant reduction in operation time.

Assessment of intraoperative bleeding in reverse shoulder arthroplasty - with or without a stem.

INTRODUCTION: The functional results of stemless reverse shoulder prostheses are similar to those with stems. However, the operative time and the bleeding appear less significant because of the absence of humeral reaming. To date, the data amongst the literature regarding this subject is limited. Thus, we report a retrospective evaluation on these 2 types of prostheses by assessing their respective intraoperative blood loss. HYPOTHESIS: Reverse shoulder arthroplasty without a stem leads to less blood loss, compared to arthroplasty with a stem. MATERIALS AND METHODS: Twenty-three patients underwent an operation for a stemless prosthesis, while 37 patients had a prosthesis with a stem. The hemoglobin was measured preoperatively, as well as postoperatively. Drainage of the operative site was maintained for two to three days. In the stem group, the preoperative hemoglobin was 14g/dL (11.7-16.6), while it was 13.1g/dL (11-15.8) in the stemless group. RESULTS: The intraoperative bleeding reached 223cm3 (80-530), with an operative duration of 81minutes (40-110) in the stemless group, compared to 260cm3 (50-1000) and 92minutes (33-110) in the stem group. On the first day postoperatively, 333cm3 (20-570) of blood had been collected by drainage for the stemless group, compared to 279cm3 (40-550) in the stem group. The amount decreased the second day, with 139cm3 (20-510) and 129cm3 (0-750) respectively. There was no difference between the two groups regarding the postoperative hemoglobin level (11g/dL). DISCUSSION: There is no significant difference concerning the blood loss between reverse shoulder replacements with and without stems. LEVEL OF EVIDENCE: III Retrospective case control study.

Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: A meta-analysis of randomized controlled trials.

AIM: The objective of this study was to assess the efficacy and safety of intravenous TXA administration in elderly patients undergoing hip fracture surgery focusing on the effect of various dosages. METHODS: A systematic search of PubMed, Embase and Cochrane Library was conducted until February 2021. Our primary outcome was peri­operative total blood loss, while secondary outcomes included transfusion rate, mean count of transfused RBC units and thromboembolic events' incidence. A subgroup analysis was performed with respect to TXA dosage. RESULTS: Out of 146 records identified, 10 randomized controlled studies met the selection criteria. Data synthesis revealed that TXA resulted in a significant reduction in total blood loss by 229.45 ml in favor of TXA; 95% CI: [189.5, 269.4] and transfusion rate by 40%, RR = 0.60; 95% CI: [0.47, 0.78]. No increase in thromboembolic events rate was observed (RR = 1.08, 95% CI: [0.68, 1.69]) Furthermore, sub-analysis with respect to TXA dosage showed no significant difference in total blood loss reduction between "single" and "multiple doses" studies (223 vs 233.5 ml, p = 0.85.), while a trend for lower complications rate was observed in patients receiving a single dose of ≤ 15 mg/kg. CONCLUSIONS: This meta-analysis provides strong evidence that TXA is a safe and effective agent to reduce perioperative blood loss in hip fracture surgery. When compared with higher dosages, a single dose of 15 mg/kg is associated with a non-significant reduction in adverse events, while achieving comparable outcomes.

To Analyze the Role of Intravenous Tranexamic Acid in Hip Fracture surgeries in Orthopedic Trauma.

INTRODUCTION: Hip fractures in orthopedic trauma cases are increasing. Majority of such patients undergoing surgery require blood transfusion of one or more units. Intravenous (I. V.) Tranexamic acid (TXA) may decrease loss of blood, decrease need of blood transfusion, and improve postoperative hemoglobin (Hb) along with lesser adverse effects. Risk of thromboembolic phenomena remains a concern. A study was done to analyze the role of I. V. TXA in hip fracture surgeries in trauma cases. MATERIALS AND METHODS: Sixty patients were included in the study; in two groups (37 males and 23 females), Group A in which two doses of I. V. TXA 15 mg/kg were given and Group B in which two doses of I. V. placebo were given. RESULTS: Total number of randomized hip arthroplasty cases was 22 (11 in Group A and 11 in Group B) whereas randomized osteosynthesis cases were 38 (19 in Group A and 19 in Group B). Mean preoperative Hb value in Group A was 10.8 gm% and in Group B was 10.7 gm% (P > 0.005. Mean postoperative Hb value in Group A was Hb 9.8 gm% and in Group B 9.5 gm% (difference of 3.061%). Mean duration of surgery in Group A was 64.2 min and in Group B was 66.3 min. Mean total blood loss (intraoperative and postoperative) in Group A was 384.6 ml and in Group B was 448.7 ml (14.29% less in Group A). A total of 14 patients in Group A (17 red blood cells [RBCs] units) and 17 patients (21 RBC units) in Group B required RBC transfusion. No major vascular event, severe bacterial infections, symptomatic deep vein thrombosis, pulmonary embolism, limb ischemia, acute coronary syndrome, or immediate postoperative mortality was noted in either group. CONCLUSION: I. V. TXA has the potential to decrease risk of blood transfusion, decrease total blood loss, and to maintain a higher postoperative Hb value with no significant adverse reactions. As the number of cases of hip fractures continues to increase along with increase in age, so the use of TXA in such cases may improve clinical outcomes, lessen number of inpatient days and hence decrease overall cost.