Journal of the Korean Orthopaedic Association (대한정형외과학회지)

Korean Orthopaedic Association (대한정형외과학회)
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Efficacy of Tranexamic Acid during Primary Total Knee Arthroplasty: Comparative Study between Intravenous Use and Topical Use

일차 슬관절 전치환술 중 트라넥삼산의 정맥 내 투여와 국소 사용의 효과에 관한 비교 연구

  • Lee, Hyun Ju (Department of Orthopedic Surgery, Gwangju Veterans Hospital) ;
  • An, Ki Yong (Department of Orthopedic Surgery, Gwangju Veterans Hospital) ;
  • Park, Ji Yeon (Department of Orthopedic Surgery, Gwangju Veterans Hospital) ;
  • Chung, Young Woo (Department of Orthopedic Surgery, Gwangju Veterans Hospital)
  • Received : 2020.03.05
  • Accepted : 2020.04.29
  • Published : 2021.04.30
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Abstract

Purpose: This study examined the effectiveness of tranexamic acid in reducing postoperative blood loss in total knee arthroplasty by comparing the methods of administration between an intravenous group, topical group, and non-tranexamic acid group. Materials and Methods: This was a retrospective case series study of patients who underwent primary total knee arthroplasty from March 2017 to February 2019 performed by a single surgeon. The study population was divided into three groups according to the method of tranexamic acid administration (Group I: intravenous group, Group II: topical group, Group III: non-tranexamic acid group). To evaluate the effectiveness of tranexamic acids, the total amount of postoperative blood loss, postoperative hemoglobin loss, and volume of red blood cell transfusion in the three groups were compared. Results: The total amount of postoperative blood loss was lower in the tranexamic acid administered group than in the non-tranexamic acid group (1,366±866 ml). Among the administration methods, the intravenous group (987±449 ml) was significantly lower than the topical group (1,136±339 ml) (p=0.004). Postoperative hemoglobin loss was lower in the tranexamic acid group than the non-tranexamic acid group. Among the administration methods, the intravenous group was lower than the topical group. The transfusion rate was higher in the non-tranexamic acid group (5.7%) than the tranexamic administered group. The transfusion rate of the intravenous group was 1.4%, and no patient required a transfusion postoperatively in the topical group. The number of postoperative thromboembolic events, as a complication of tranexamic acid, was similar in the three groups. Conclusion: Tranexamic acid was effective in reducing postoperative blood loss after primary total knee arthroplasty compared to the non-tranexamic acid administered group. No significant difference in the complications induced by tranexamic acid was observed among the three groups.

목적: 일차 슬관절 전치환술을 받은 환자들에게서 트라넥삼산의 효능을 확인하고, 트라넥삼산의 정맥 내 사용 방법과 관절 내 투여 군을 비교하여 어떤 방법이 혈액 손실 감소 효과가 더 있는지 알아보고자 하였다. 대상 및 방법: 이 연구는 광주보훈병원에서 2017년 3월부터 2019년 2월까지 일차 슬관절 전치환술을 받은 환자들에 대한 후향적 연구이다. 단측 일차 슬관절 전치환술을 시행 받은 총 210명의 환자가 연구에 포함되었다. 트라넥삼산 사용 방법에 따라 각각 70명의 환자들에 대해 3개의 그룹으로 나누었다(Group I: 정맥 내 투여 군, Group II: 관절 내 투여 군, Group III: 트라넥삼산을 사용하지 않은 군). 그룹 간 수술 후 총 실혈량, 헤모글로빈 감소치, 수혈 단위를 비교하였다. 결과: 총 실혈량은 관절 내 투여 군(1,136±339 ml) 및 트라넥삼산을 사용하지 않은 군(1,366±866 ml)보다 정맥 내 사용 군(987±449 ml)에서 더 낮았다(p=0.004). 수술 후 헤모글로빈의 손실 또한 정맥 내 사용 군(1.8 g/dl)에서 관절 내 투여 군(2.9 g/dl)이나 투여하지 않은 군(3.5 g/dl)보다 현저히 낮았다(p<0.01). 수혈 빈도는 트라넥삼산을 사용하지 않은 그룹(5.7%)에서 더 높았으며 정맥 내 사용 시 1.4%를 보이고, 관절 내 투여한 군에서 수혈을 받은 환자는 없었다. 혈전색전증의 발생 빈도는 그룹 간 통계적으로 유의하지 않았다. 결론: 일차 슬관절 전치환술 시행 시 트라넥삼산을 사용한 환자 군에서 사용한지 않은 군에 비해 총 실혈량을 유의하게 감소시켰고, 관절 내 투여보다는 정맥 내로 투여하는 것이 더 효과적이었다. 정맥 내 투여로 인한 합병증은 관절 내 투여 및 트라넥삼산을 사용하지 않은 군과 비교해 유의한 차이는 없었다.

Keywords

References

  1. Huang ZY, Pei FX, Ma J, et al. Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial. Arch Orthop Trauma Surg. 2014;134:561-70. https://doi.org/10.1007/s00402-014-1948-1
  2. Lotke PA, Faralli VJ, Orenstein EM, Ecker ML. Blood loss after total knee replacement. Effects of tourniquet release and continuous passive motion. J Bone Joint Surg Am. 1991;73:1037-40. https://doi.org/10.2106/00004623-199173070-00011
  3. Su EP, Su S. Strategies for reducing peri-operative blood loss in total knee arthroplasty. Bone Joint J. 2016;98(1 Suppl A):98-100. https://doi.org/10.1302/0301-620X.98B.36430
  4. Ishii Y, Noguchi H, Sato J, Tsuchiya C, Toyabe S. Effect of a single injection of tranexamic acid on blood loss after primary hybrid TKA. Knee. 2015;22:197-200. https://doi.org/10.1016/j.knee.2015.01.003
  5. Xie J, Ma J, Yao H, Yue C, Pei F. Multiple boluses of intravenous tranexamic acid to reduce hidden blood loss after primary total knee arthroplasty without tourniquet: a randomized clinical trial. J Arthroplasty. 2016;31:2458-64. https://doi.org/10.1016/j.arth.2016.04.034
  6. McEvoy MT, Shander A. Anemia, bleeding, and blood transfusion in the intensive care unit: causes, risks, costs, and new strategies. Am J Crit Care. 2013;22(6 Suppl):eS1-13; quiz eS14. https://doi.org/10.4037/ajcc2013729
  7. Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients. J Bone Joint Surg Br. 1996;78:434-40. https://doi.org/10.1302/0301-620X.78B3.0780434
  8. Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025-35. https://doi.org/10.1001/jama.2016.9185
  9. Hiippala S, Strid L, Wennerstrand M, et al. Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth. 1995;74:534-7. https://doi.org/10.1093/bja/74.5.534
  10. Karam JA, Bloomfield MR, DiIorio TM, Irizarry AM, Sharkey PF. Evaluation of the efficacy and safety of tranexamic acid for reducing blood loss in bilateral total knee arthroplasty. J Arthroplasty. 2014;29:501-3. https://doi.org/10.1016/j.arth.2013.08.005
  11. Chen S, Li J, Peng H, Zhou J, Fang H, Zheng H. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. Int Orthop. 2014;38:355-9. https://doi.org/10.1007/s00264-013-2177-x
  12. Aggarwal AK, Shashikanth VS, Marwaha N. Platelet-rich plasma prevents blood loss and pain and enhances early functional outcome after total knee arthroplasty: a prospective randomised controlled study. Int Orthop. 2014;38:387-95. https://doi.org/10.1007/s00264-013-2136-6
  13. Dong Z, Han L, Song Y, Qi J, Wang F. Hemostatic techniques to reduce blood transfusion after primary TKA: a meta-analysis and systematic review. Arch Orthop Trauma Surg. 2019;139:1785-96. https://doi.org/10.1007/s00402-019-03271-y
  14. Panni AS, Cerciello S, Vasso M, Del Regno C. Knee flexion after total knee arthroplasty reduces blood loss. Knee Surg Sports Traumatol Arthrosc. 2014;22:1859-64. https://doi.org/10.1007/s00167-014-2983-8
  15. Park JH, Rasouli MR, Mortazavi SM, Tokarski AT, Maltenfort MG, Parvizi J. Predictors of perioperative blood loss in total joint arthroplasty. J Bone Joint Surg Am. 2013;95:1777-83. https://doi.org/10.2106/JBJS.L.01335
  16. Zhao-Yu C, Yan G, Wei C, Yuejv L, Ying-Ze Z. Reduced blood loss after intra-articular tranexamic acid injection during total knee arthroplasty: a meta-analysis of the literature. Knee Surg Sports Traumatol Arthrosc. 2014;22:3181-90. https://doi.org/10.1007/s00167-013-2814-3
  17. Lee GC, Kim DH, Lee JW, Kang SW, Cho SW. Comparison of blood loss between intra-articular and intravenous tranexamic acid following primary total knee arthroplasty. J Korean Orthop Assoc. 2018;53:152-8. https://doi.org/10.4055/jkoa.2018.53.2.152
  18. Bezwada HR, Nazarian DG, Henry DH, Booth RE Jr, Mont MA. Blood management in total joint arthroplasty. Am J Orthop. 2006;35:458-64.
  19. Lee SY, Chong S, Balasubramanian D, Na YG, Kim TK. What is the ideal route of administration of tranexamic acid in TKA? A randomized controlled trial. Clin Orthop Relat Res. 2017;475:1987-96. https://doi.org/10.1007/s11999-017-5311-z
  20. Dai WL, Zhou AG, Zhang H, Zhang J. Most effective regimen of tranexamic acid for reducing bleeding and transfusions in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Knee Surg. 2018;31:654-63. https://doi.org/10.1055/s-0037-1606376
  21. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery. 1962;51:224-32.
  22. Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty? Correct blood loss management should take hidden loss into account. Knee. 2000;7:151-5. https://doi.org/10.1016/S0968-0160(00)00047-8
  23. White CC 4th, Eichinger JK, Friedman RJ. Minimizing blood loss and transfusions in total knee arthroplasty. J Knee Surg. 2018;31:594-9. https://doi.org/10.1055/s-0038-1648223
  24. Wei W, Dang S, Duan D, Wei L. Comparison of intravenous and topical tranexamic acid in total knee arthroplasty. BMC Musculoskelet Disord. 2018;19:191. https://doi.org/10.1186/s12891-018-2122-7
  25. Pitta M, Zawadsky M, Verstraete R, Rubinstein A. Intravenous administration of tranexamic acid effectively reduces blood loss in primary total knee arthroplasty in a 610-patient consecutive case series. Transfusion. 2016;56:466-71. https://doi.org/10.1111/trf.13354
  26. Ishida K, Tsumura N, Kitagawa A, et al. Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty. Int Orthop. 2011;35:1639-45. https://doi.org/10.1007/s00264-010-1205-3
  27. Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br. 2001;83:702-5. https://doi.org/10.1302/0301-620X.83B5.0830702
  28. Orpen NM, Little C, Walker G, Crawfurd EJ. Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomised controlled trial of 29 patients. Knee. 2006;13:106-10. https://doi.org/10.1016/j.knee.2005.11.001
  29. Goldstein M, Feldmann C, Wulf H, Wiesmann T. Tranexamic acid prophylaxis in hip and knee joint replacement. Dtsch Arztebl Int. 2017;114:824-30.
  30. Klak M, Anakkala N, Wang W, et al. Tranexamic acid, an inhibitor of plasminogen activation, aggravates staphylococcal septic arthritis and sepsis. Scand J Infect Dis. 2010;42:351-8. https://doi.org/10.3109/00365540903510690