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A meta-analysis of the effectiveness and safety of using tranexamic acid in primary unilateral total knee arthroplasty

Published:April 29, 2013DOI:https://doi.org/10.1016/j.jss.2013.03.099

      Abstract

      Background

      To evaluate the effectiveness and safety of tranexamic acid (TEA) treatment in reducing perioperative blood loss and transfusion for patients receiving primary unilateral total knee arthroplasty (TKA) and to explore the most effective and safe protocol.

      Materials and methods

      This study was based on Cochrane methodology for conducting meta-analyses. Only randomized controlled trials were eligible for this study. The participants were adults who had undergone primary unilateral TKA. The Review Manager Database (RevMan version 5.0, The Cochrane Collaboration, 2008) was used to analyze selected studies.

      Results

      Nineteen randomized controlled trials involving 1114 patients were included. The use of TEA reduced postoperative drainage by a mean of 290 mL (95% confidence interval [CI] −385 to −196], total blood loss by a mean of 570 mL (95% CI −663 to −478), the number of blood transfusions per patient by 0.96 units (95% CI −1.32 to −0.59), and the volumes of blood transfusions per patient −440 mL (95% CI −518 to −362). TEA led to a significant reduction in the proportion of patients requiring blood transfusion (relative risk 0.39). There were no significant differences in venous thromboembolism or other adverse events among the study groups.

      Conclusions

      Intravenous TEA could significantly reduce perioperative blood loss and blood transfusion requirements following primary unilateral TKA. Its application is not associated with increased risk of venous thromboembolisms or other adverse events.

      Keywords

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      References

        • Callaghan J.J.
        • O’Rourke M.R.
        • Liu S.S.
        Blood management: issues and options.
        J Arthroplasty. 2005; 20: 51
        • Keating E.M.
        • Meding J.B.
        • Faris P.M.
        • Ritter M.A.
        Predictors of transfusion risk in elective knee surgery.
        Clin Orthop Relat Res. 1998; 357: 50
        • Mylod Jr., A.G.
        • France M.P.
        • Muser D.E.
        • Parsons J.R.
        Perioperative blood loss associated with total kneearthroplasty: a comparison of procedures performed with and without cementing.
        J Bone Joint Surg Am. 1990; 72: 1010
        • Bierbaum B.E.
        • Calaghan J.J.
        • Galante J.O.
        • Rubash H.E.
        • Tooms R.E.
        • Welch R.B.
        An analysis of blood management in patients having a total hip or knee arthroplasty.
        J Bone Joint Surg Am. 1999; 81: 2
        • Janssens M.
        • Joris J.
        • David J.L.
        • Lemaire R.
        • Lamy M.
        High-dose aprotinin reduces blood loss in patients undergoing total hip replacement surgery.
        Anesthesiology. 1994; 80: 23
        • Risberg B.
        The response of the fibrinolytic system in trauma.
        Acta Chir Scand Suppl. 1985; 522: 245
        • Aglietti P.
        • Baldini A.
        • Vena L.M.
        • Abbate R.
        • Fedi S.
        • Falciani M.
        Effect of tourniquet use on activation of coagulation in total knee arthroplasty.
        Clin Orthop Relat Res. 2000; 371: 169
        • Kruithof E.K.
        • Nicolosa G.
        • Bachmann F.
        Plasminogen activator inhibitor 1: development of a radioimmunoassay and observations on its plasma concentration during venous occlusion and after platelet aggregation.
        Blood. 1987; 70: 1645
        • Petaja J.
        • Myllynen P.
        • Myllyla G.
        • Vahtera E.
        Fibrinolysis after application of a pneumatic tourniquet.
        Acta Chir Scand. 1987; 153: 647
        • Fahmy N.R.
        • Patel D.G.
        Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet.
        J Bone Joint Surg Am. 1981; 63: 461
        • Henry D.A.
        • Moxey A.J.
        • Carless P.A.
        • et al.
        Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion.
        Cochrane Database Syst Rev. 2001; : CD001886
        • Sasanuma H.
        • Sekiya H.
        • Takatoku K.
        • Takada H.
        • Sugimoto N.
        • Hoshino Y.
        Efficient strategy for controlling postoperative hemorrhage in total knee arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 921
        • Hynes M.
        • Calder P.
        • Scott G.
        The use of tranexamic acid to reduce blood loss during total knee arthroplasty.
        Knee. 2003; 10: 375
        • Lozano M.
        • Basora M.
        • Peidro L.
        • et al.
        Effectiveness and safety of tranexamic acid administration during total knee arthroplasty.
        Vox Sang. 2008; 95: 39
        • Ralley F.E.
        • Berta D.
        • Binns V.
        • Howard J.
        • Naudie D.D.
        One intraoperative dose of tranexamic Acid for patients having primary hip or knee arthroplasty.
        Clin Orthop Relat Res. 2010; 468: 1905
        • Engel J.M.
        • Hohaus T.
        • Ruwoldt R.
        • Menges T.
        • Jürgensen I.
        • Hempelmann G.
        Regional hemostatic status and blood requirements after total knee arthroplasty with and without tranexamic acid or aprotinin.
        Anesth Analg. 2001; 92: 775
      1. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 4.2.5, 2005. [Online]

      2. Handoll H, Elstub L, Elliott J, et al. Cochrane Bone, Joint and Muscle Trauma Group. About the Cochrane collaboration (Cochrane Review Groups (CRGS)) 2008; Issue 4. Art. No: MUSKINJ. Available from: http://bjmtg.cochrane.org/sites/bjmtg.cochrane.org/files/uploads/Quality%20assessment%20tool.pdf.

        • Maniar R.N.
        • Kumar G.
        • Singhi T.
        • Nayak R.M.
        • Maniar P.R.
        Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients.
        Clin Orthop Relat Res. 2012; 470: 2605
        • Charoencholvanich K.
        • Siriwattanasakul P.
        Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial.
        Clin Orthop Relat Res. 2011; 469: 2874
        • Lin P.C.
        • Hsu C.H.
        • Chen W.S.
        • Wang J.W.
        Does tranexamic acid save blood in minimally invasive total knee arthroplasty.
        Clin Orthop Relat Res. 2011; 469: 1995
        • Kakar P.N.
        • Gupta N.
        • Govil P.
        • Shah V.
        Efficacy and safety of tranexamic acid in control of bleeding following TKR: a randomized clinical trial.
        Indian J Anaesth. 2009; 53: 667
        • Alvarez J.C.
        • Santiveri F.X.
        • Ramos I.
        • Vela E.
        • Puig L.
        • Escolano F.
        Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied.
        Transfusion. 2008; 48: 519
        • Zhang F.
        • Gao Z.
        • Yu J.
        Clinical comparative studies on effect of tranexamic acid on blood loss associated with total knee arthroplasty.
        Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2007; 21: 1302
        • Camarasa M.A.
        • Olle G.
        • Serra-Prat M.
        • et al.
        Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial.
        Br J Anaesth. 2006; 96: 576
        • Orpen N.M.
        • Little C.
        • Walker G.
        • Crawfurd E.J.
        Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomised controlled trial of 29 patients.
        Knee. 2006; 13: 106
        • Zohar E.
        • Ellis M.
        • Ifrach N.
        • Stern A.
        • Sapir O.
        • Fredman B.
        The postoperative blood-sparing efficacy of oral versus intravenous tranexamic acid after total knee replacement.
        Anesth Analg. 2004; 99: 1679
        • Good L.
        • Peterson E.
        • Lisander B.
        Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement.
        Br J Anaesth. 2003; 90: 596
        • Veien M.
        • Sørensen J.V.
        • Madsen F.
        • Juelsgaard P.
        Tranexamic acid given intraoperatively reduces blood loss after total knee replacement.
        Acta Anaesthesiol Scand. 2002; 46: 1206
        • 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
        • Ellis M.H.
        • Fredman B.
        • Zohar E.
        • Ifrach N.
        • Jedeikin R.
        The effect of tourniquet application, tranexamic acid, and desmopressin on the procoagulant and fibrinolytic systems during total knee replacement.
        J Clin Anesth. 2001; 13: 509
        • Ido K.
        • Neo M.
        • Asada Y.
        • et al.
        Reduction of blood loss using tranexamic acid in total knee and hip arthroplasties.
        Arch Orthop Trauma Surg. 2000; 120: 518
        • Jansen A.J.
        • Andreica S.
        • Claeys M.
        • D'Haese J.
        • Camu F.
        • Jochmans K.
        Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty.
        Br J Anaesth. 1999; 83: 596
        • Hiippala S.T.
        • Strid L.J.
        • Wennerstrand M.I.
        • et al.
        Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty.
        Anesth Analg. 1997; 84: 839
        • 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
        • 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
        • Klenerman L.
        • Chakrabarti R.
        • Mackie I.
        • Brozovic M.
        • Stirling Y.
        Changes in haemostatic system after application of a tourniquet.
        Lancet. 1977; 1: 970
        • Dunn C.J.
        • Goa K.L.
        Tranexamic acid: a review of its use in surgery and other indications.
        Drugs. 1999; 57: 1005
        • Eubanks J.D.
        Antifibrinolytics in major orthopaedic surgery.
        J Am Acad Orthop Surg. 2010; 18: 132
        • Cid J.
        • Lozano M.
        Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials.
        Transfusion. 2005; 45: 1302
        • Zufferey P.
        • Merquiol F.
        • Laporte S.
        • et al.
        Do antifibrinolytics reduce allogeneic blood transfusion in orthopedic surgery?.
        Anesthesiology. 2006; 105: 1034
        • Kagoma Y.K.
        • Crowther M.A.
        • Douketis J.
        • Bhandari M.
        • Eikelboom J.
        • Lim W.
        Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials.
        Thromb Res. 2009; 123: 687
        • Yang Z.G.
        • Chen W.P.
        • Wu L.D.
        Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis.
        J Bone Joint Surg Am. 2012; 94: 1153
        • Nilsson I.M.
        Clinical pharmacology of aminocaproic and tranexamic acids.
        J Clin Pathol Suppl. 1980; 14: 41