ObjectiveTo evaluate the effectiveness and safety of tranexamic acid (TXA) combined with intraoperative controlled hypotension (ICH) for reducing perioperative blood loss in primary total hip arthroplasty (THA).MethodsThe clinical data of 832 patients with initial THA due to osteonecrosis of femoral head between January 2017 and July 2020 were retrospectively analyzed. All patients received TXA treatment, and 439 patients (hypotension group) received ICH treatment with an intraoperative mean arterial pressure (MAP) below 80 mm Hg (1 mm Hg=0.133 kPa) while 393 patients (normotension group) received standard general anesthesia with no special invention on blood pressure. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists (ASA) classification, basic arterial pressure, hip range of motion, internal diseases, preoperative hemoglobin (HB) and hematocrit (HCT), coagulation function, surgical approach, and TXA dosage between the two groups (P>0.05). The perioperative blood loss and blood transfusion, anesthesia and operation time, hospitalization stay, postoperative range of motion, and complications were recorded and compared between the two groups. The patients were further divided into MAP<70 mm Hg group (group A), MAP 70-80 mm Hg group (group B), and normotension group (group C). The perioperative blood loss and postoperative complications were further analyzed to screen the best range of blood pressure.ResultsThe intraoperative MAP, total blood loss, dominant blood loss, recessive blood loss, blood transfusion rate and blood transfusion volume, anesthesia time, operation time, and hospitalizarion stay in the hypotension group were significantly lower than those in the normotension group (P<0.05). The postoperative hip flexion range of motion in the hypotension group was significantly better than that of the normotension group (Z=2.743, P=0.006), but there was no significant difference in the abduction range of motion between the two groups (Z=0.338, P=0.735). In terms of postoperative complications, the incidence of postoperative hypotension in the hypotension group was significantly higher than that in the normotension group (χ2=6.096, P=0.014), and there was no significant difference in the incidence of other complications (P>0.05). There was no stroke, pulmonary embolism, or deep vein thrombosis in the two groups, and no patients died during hospitalization. Subgroup analysis showed that there was no significant difference in total blood loss, dominant blood loss, and recessive blood loss in groups A and B during the perioperative period (P>0.05), which were significantly lower than those in group C (P<0.05). There was no significant difference in blood transfusion rate, blood transfusion volume, and incidence of acute myocardial injury between 3 groups (P>0.05); the incidence of acute kidney injury in group A was significantly higher than that in group B, and the incidence of postoperative hypotension in group A was significantly higher than that in groups B and C (P<0.05), but no significant difference was found between groups B and C (P>0.05).ConclusionThe combination of TXA and ICH has a synergistic effect. Controlling the intraoperative MAP at 70-80 mm Hg can effectively reduce the perioperative blood loss during the initial THA, and it is not accompanied by postoperative complications.
ObjectiveTo investigate the efficacy and safety of multiple-dose intravenous tranexamic acid (TXA) for reducing blood loss in complex tibial plateau fractures with open reduction internal fixation by a prospective randomized controlled trial. MethodsA study was conducted on patients with Schatzker type Ⅳ-Ⅵ tibial plateau fractures admitted between August 2020 and December 2022. Among them, 88 patients met the selection criteria and were included in the study. They were randomly allocated into 3 groups, the control group (28 cases), single-dose TXA group (31 cases), and multiple-dose TXA group (29 cases), using a random number table method. There was no significant difference (P>0.05) in terms of age, gender, body mass index, the Schatzker type and side of fracture, laboratory examinations [hemoglobin (Hb), activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen (Fib), international normalized ratio (INR), D-dimer, and interleukin 6 (IL-6)], and preoperative blood volume. The control group received intravenous infusion of 100 mL saline at 15 minutes before operation and 3, 6, and 24 hours after the first administration. The single-dose TXA group received intravenous infusion of 1 g TXA (dissolved in 100 mL saline) at 15 minutes before operation, followed by an equal amount of saline at each time point after the first administration. The multiple-dose TXA group received intravenous infusion of 1 g TXA (dissolved in 100 mL saline) at each time point. The relevant indicators were recorded and compared between groups to evaluate the effectiveness and safety of TXA, including hospital stays, operation time, occurrence of infection; the occurrence of lower extremity deep vein thrombosis, intermuscular vein thrombosis, and pulmonary embolism at 1 week after operation; the lowest postoperative Hb value and Hb reduction rate, the difference (change value) between pre- and post-operative APTT, PT, Fib, and INR; D-dimer and IL-6 at 24 and 72 hours after operation; total blood loss, intraoperative blood loss, hidden blood loss, drainage flow during 48 hours after operation, and postoperative blood transfusion. Results ① TXA efficacy evaluation: the lowest Hb value in the control group was significantly lower than that in the other two groups (P<0.05), and there was no significant difference between the single- and multiple-dose TXA groups (P>0.05). The Hb reduction rate, total blood loss, intraoperative blood loss, drainage flow during 48 hours after operation, and hidden blood loss showed a gradual decrease trend in the control group, single-dose TXA group, and multiple-dose TXA group. And differences were significant (P<0.05) in the Hb reduction rate and drainage flow during 48 hours after operation between groups, and the total blood loss and hidden blood loss between control group and other two groups. ② TXA safety evaluation: no lower extremity deep vein thrombosis or pulmonary embolism occurred in the three groups after operation, but 3, 4, and 2 cases of intermuscular vein thrombosis occurred in the control group, single-dose TXA group, and multiple-dose TXA group, respectively, and the differences in the incidences between groups were not significant (P>0.05). There was no significant difference in the operation time between groups (P>0.05). But the length of hospital stay was significantly longer in the control group than in the other groups (P<0.05); there was no significant difference between the single- and multiple-dose TXA groups (P>0.05). ③ Effect of TXA on blood coagulation and inflammatory response: the incisions of the 3 groups healed by first intention, and no infections occurred. The differences in the changes of APTT, PT, Fib, and INR between groups were not significant (P>0.05). The D-dimer and IL-6 in the three groups showed a trend of first increasing and then decreasing over time, and there was a significant difference between different time points in the three groups (P<0.05). At 24 and 72 hours after operation, there was no significant difference in D-dimer between groups (P>0.05), while there was a significant difference in IL-6 between groups (P<0.05). Conclusion Multiple intravenous applications of TXA can reduce perioperative blood loss and shorten hospital stays in patients undergoing open reduction and internal fixation of complex tibial plateau fractures, provide additional fibrinolysis control and ameliorate postoperative inflammatory response.
Objective To investigate the effect and safety of time of temporarily-closed wound drainage on blood loss of primary total knee arthroplasty (TKA) after intravenous and intra-articular injection of tranexamic acid (TXA). Methods Eighty female patients were selected from 102 patients who underwent primary TKA between September 2015 and July 2016, who were randomly divided into 4 groups: control group (group A), 30 minutes group (group B), 60 minutes group (group C), and 90 minutes group (group D), 20 patients each group. No significant difference was found in age, body mass index, side, pathogen, duration, and preoperative hemoglobin, albumin, and hematocrit between 4 groups (P>0.05). All the patients received intravenous injection of 1 g TXA at 10 minutes before removing the tourniquet. The patients in group A were injected with 60 mL normal saline into the articular cavity and closed drainage after surgery, while the patients in groups B, C, and D were injected with 60 mL TXA into the articular cavity and closed drainage for 30, 60, and 90 minutes respectively. The volume of drainage at 24 hours after operation, the total blood loss, the postoperative hemoglobin level, maximum hemoglobin loss, albumin loss, the volume and frequency of blood transfusion, venous thrombo embolism rate, and pulmonary embolism rate were recorded and compared between groups. Results The volume of drainage and total blood loss in groups B, C, and D were less than those of group A, showing significant difference between groups C, D and group A (P<0.05), but no significant difference between group B and group A (P>0.05). The volume of drainage at 24 hours after operation in group B was higher than that in groups C and D, showing significant difference between groups B and D (P<0.05), but no significant difference was found between groups C and D (P>0.05). There was no significant difference in the total blood loss between groups B, C, and D (P>0.05). The hemoglobin loss and albumin loss gradually decreased from groups A to D, but no significant difference was found between groups (P>0.05). No venous thrombo embolism and pulmonary embolism occurred. The hemoglobin value decreased to 28 g/L at 3 days after operation in 1 patient of group D, who received venous transfusion of 20 g human albumin. Conclusion Intravenous and topical application of TXA in TKA can significantly decrease postoperative bleeding. Topical TXA combined with 60 minutes temporarily-closed wound drainage may reduce postoperative blood loss to the greatest extent without increasing the risk of venous thrombo and pulmonary embolism event after TKA．
ObjectiveTo review the perioperative blood management (PBM) of total knee arthroplasty (TKA) and total hip arthroplasty (THA).MethodsRecent researches on PBM for TKA and THA were comprehensively read and summarized. Then the advantages and disadvantages of various measures together with the clinical experience of West China Hospital of Sichuan University were evaluated from three aspects, including optimizing hematopoiesis, reducing blood loss and blood transfusion, which could provide a basis for clinical selection.ResultsThere are many PBM methods in TKA and THA, among which the optimization of hematopoiesis mainly includes the application of perioperative iron and erythropoietin. Measures to reduce bleeding include the use of tourniquet, intraoperative controlled hypotension, and perioperative antifibrinolytic agents. Autologous blood transfusion includes preoperative autologous blood donation, hemodilution and cell salvage. Allogeneic blood transfusion is the ultimate treatment for anemia. The application of erythropoietin combined with iron therapy for blood mobilization before surgery together with intraoperative controlled hypotension for bleeding control and the multiple use of tranexamic acid can achieve satisfactory clinical results.ConclusionIn the perioperative period of TKA and THA, single or multiple use of different blood management measures should be considered carefully according to the physical and economic conditions of patients individually, so as to reduce the blood loss and allogeneic blood transfusion optimally, and finally accelerate the recovery of patients.
ObjectiveTo analyze the effectiveness of fast track protocol of geriatric intertrochanteric fracture on operative waiting time, operation time, perioperative blood loss, providing data support for clinical therapy.MethodsThe clinical data of 240 elderly patients with intertrochanteric fracture admitted between January 2015 and December 2018 were retrospectively analyzed. They were divided into traditional protocol group (148 cases, group A) and fast track group (92 cases, group B). All patients were treated with closed reduction intramedullary nail (proximal femoral nail antirotation) surgery. There was no significant difference in gender, age, sides, fracture classification, fracture type, complications, the proportion of patients with more than 3 kinds of medical diseases, and the time from injury to admission between the two groups (P>0.05). Analysis index included operative waiting time (hospitalization to operation time), operation time, percentage of operation performing in 48 and 72 hours, percentage of transfusion, changes of hematocrit (Hct) at different stage (admission, operation day, and postoperative 1, 3 days), blood loss by fracture and cephalomedullary nail, intraoperative dominant blood loss, total blood loss in perioperative period were recorded and compared.ResultsThe operative waiting time, operation time, Hct on operation day and postoperative 3 days, blood loss by fracture, transfusion volume, and total blood loss in perioperative period in group B were significantly less than those in group A (P<0.05), and the percentage of operation performing in 48 and 72 hours in group B were significantly higher than those in group A (P<0.05). There was no signifcant difference in Hct on admission and postoperative 1 day, intraoperative dominant blood loss, percentage of transfusion, blood loss by cephalomedullary nail between the two groups (P>0.05).ConclusionFast track can shorten the operative waiting time of geriatric intertrochanteric fracture, reduce the blood loss by fracture, total blood loss in perioperative period, and transfusion volume. Early operation is conducive to improve the anemia status of patients during perioperative period.
Objective To compare the efficacy and safety of intra-articular combined with intravenous administration of tranexamic acid (TXA) with different dosage for reducing blood loss in primary total knee arthroplasty (TKA). Methods Between January 2017 and June 2017, 90 patients suffering from unilateral osteoarthritis who underwent primary TKA were randomly scheduled to three interventions, named groups A, B, and C. Single dosage of TXA via intravenous injection (IV) and different dosages of TXA via intra-articular injection (IA) were utilized in three groups, respectively. All patients in three groups received 1 g TXA IV at 10 minutes preoperatively, and received 1, 2, and 3 g TXA IA diluted in 50 mL saline after wound closure in groups A, B and C, respectively. The age, gender, body mass index, affected side of the knee, grade of osteoarthritis, grade of America Society of Anesthesiologist, preoperative hemoglobin (Hb) concentration, platelet count, preoperative prothrombin time, and activated partial thromboplastin time were not significantly different between groups (P>0.05). The postoperative wound blood drainage, Hb concentration at 1, 3, and 7 days after operation, transfusion rate, and thromboembolic complications were observed. All patients were routinely observed for deep vein thrombosis (DVT) by the color Doppler ultrasonography at 1 week, 1 month, and 3 months after operation, and the symptomatic pulmonary embolism (PE) were observed. Results All patients in three groups were followed up 7-12 months (mean, 8.4 months). There was no significant difference in operation time between groups (P>0.05). The postoperative wound blood drainage was significantly less in groups B and C than that in group A (P<0.05), whereas no significant difference was found between group B and group C (P>0.05). Incision skin necrosis occurred in 1 case of group B and fat liquefaction occurred in 1 case of group C. The other incisions of 3 groups healed by first intention. There was no significant difference in incision complication incidence between groups. The Hb concentration was significantly higher in groups B and C than that in group A at 1, 3, and 7 days after operation (P<0.05). While between group B and group C, the significant difference of Hb concentration only existed at 1 day after operation (P<0.05). The number of patients who got blood transfusion was significantly less in group B (4 cases, 13.3%) and group C (5 cases, 16.7%) than that in group A (9 cases, 30%) (P< 0.05), but no significant difference was found between group B and group C (P>0.05). The result of color Doppler ultrasonography showed that 1 case got DVT in the contralateral calf at 3 weeks in group B. And there was no symptomatic PE in 3 groups. Conclusion Combined administration of IV and IA TXA in a clinically relevant reduction in blood loss was effective and safe in primary TKA, and no thromboembolic complication was observed. The combination of 1 g IV with 2 g IA could be the optional choice.
Objective A prospective randomized controlled trial was conducted to study the effectiveness and safety of intravenous different doses tranexamic acid (TXA) in single-level unilateral minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Methods The patients treated with single-level unilateral MIS-TLIF between September 2019 and October 2020 were enrolled and randomly classified into low-dose TXA (LD) group (n=39), high-dose TXA (HD) group (n=39), and placebo-controlled (PC) group (n=38). The LD, HD, and PC groups received intravenous TXA 20 mg/kg, TXA 50 mg/kg, the same volume of normal saline at 30 minute before skin incision after general anesthesia, respectively. There was no significant difference on baseline characteristics and preoperative laboratory results among 3 groups (P>0.05), including age, gender, body mass index, surgical segments, hematocrit (HCT), hemoglobin (HGB), prothrombin time (PT), international normalized ratio (INR), D-dimer, fibrin degradation products (FDP), activated partial prothromboplastin time (APTT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine (Cr), urea. The intraoperative blood loss (IBL), postoperative drainage volume, operation time, total blood loss (TBL), hidden blood loss (HBL), blood transfusion, hematological examination indexes on the first day after operation, and the incidence of complications within 1 month were compared among the 3 groups. Results There were 3, 2, and 4 patients in the LD, HD, and PC groups who underwent autologous blood transfusion, respectively, and there was no allogeneic blood transfusion patients in the 3 groups. There was no significant difference in IBL, postoperative drainage volume, and operation time between groups (P>0.05). The TBL, HBL, and the decreased value of HGB in LD and HD groups were significantly lower than those in PC group (P<0.05), and TBL and HBL in HD group were significantly lower than those in LD group (P<0.05); the decreased value of HGB between LD group and HD group showed no significant difference (P>0.05). On the first day after operation, D-dimer in LD and HD groups were significantly lower than that in PC group (P<0.05); there was no significant difference between LD and HD groups (P>0.05). There was no significant difference in other hematological indexes between groups (P>0.05). All patients were followed up 1 month, and there was no TXA-related complication such as deep venous thrombosis of lower extremity, pulmonary embolism, and epilepsy in the 3 groups. ConclusionIntravenous administration of TXA in single-level unilateral MIS-TLIF is effective and safe in reducing postoperative TBL and HBL within 1 day in a dose-dependent manner. Also, TXA can reduce postoperative fibrinolysis markers and do not increase the risk of thrombotic events, including deep venous thrombosis and pulmonary embolism.
ObjectiveTo summarize research progress of the effect of knee flexion position on postoperative blood loss and knee range of motion (ROM) after total knee arthroplasty (TKA).MethodsThe relevant literature at home and abroad was reviewed and summarized from mechanism, research status, progress, and clinical outcome. The differences of clinical results caused by different positions, flexion angles, and keeping time were compared.ResultsKeeping knee flexion after TKA can reduce postoperative blood loss through the angle change of blood vessels and increase knee early ROM by improving flexion muscle strength. When the flexion angle of the knee is large and the flexion position is keeping for a long time, the postoperative blood loss and the knee ROM can be significantly improved. However, the amount of blood loss and ROM are not further improved in the patients with keeping knee flexion for more than 24 hours compared with less than 24 hours.ConclusionKeeping knee flexion after TKA is a simple and effective method to reduce postoperative blood loss and improve knee ROM. However, the optimal knee flexion angle and time are needed to be further explored.
Objective During primary total knee arthroplasty (TKA), anticoagulant drugs are used for prevention of major venous thrombosis of lower limbs, and this often leads to the increase of perioperative blood loss. To retrospectively analyse the impact of low molecular weight heparin on hidden blood loss and transfusion rate after primary TKA by comparing with the use of aspirin. Methods Between October 2007 and August 2009, the clinical data from 286 patients undergoing primary TKA surgery were retrospectively analyzed. In accordance with different anticoagulation methods, the cases were divided into 2 groups, the trial group (n=166) and the control group (n=120). In the trial group, the patients received low molecular weight heparin (4 000-6 000 U/day) from 8-12 hours after TKA for 14 days; there were 27 males and 139 females with an average age of 66.1 years (range, 22-82 years); the body mass index (BMI) was 26.79 ± 3.87; and the locations were the left knee in 99 cases and the right knee in 67 cases with an average disease duration of 4.1 years (range, 1.8-8.6 years). In the control group, the patients received aspirin (150 mg/day) for 14 days; there were 21 males and 99 females with an average age of 64.9 years (range, 40-84 years); the BMI was 27.87 ± 3.62; and the locations were the left knee in 78 cases and the right knee in 42 cases with an average disease duration of 4.9 years (range, 1.5-8.2 years). There was no significant difference in the general data between 2 groups (P gt; 0.05). Results The incisions healed by first intention in all patients. Postoperative deep venous thrombosis occurred in 37 patients of the trial group and in 28 cases of the control group. All the patients were followed up 12-34 months (mean, 21.6 months). There were significant differences in the United States Hospital for Special Surgery (HSS) score of 2 groups between before surgery and after surgery (P lt; 0.05). The hidden blood loss was (40.55 ± 37.75) g/L in the trial group and (32.52 ± 40.13) g/L in the control group, showing significant difference (t=3.387, P=0.001); the dominant blood loss was (24.08 ± 14.63) g/L and (27.91 ± 18.47) g/L respectively, showing no significant difference (t= —1.899, P=0.059). The blood transfusion rates were 40.4% (67/166) in the trial group and 30.0% (36/120) in the control group, showing no significant difference (χ2=2.771, P=0.081); the transfusion volumes were (1.44 ± 4.03) U and (0.97 ± 3.50) U respectively, showing significant difference (t=2.071, P=0.039). Conclusion The low molecular weight heparin has effect on the hidden blood loss after primary TKA, which may increase postoperative blood loss and blood transfusion rate. The changes in hemoglobin should be monitored during the anticoagulant therapy, and the blood volume should be added promptly.
Objective To investigate the effect of applying a tourniquet on perioperative blood loss and short-term effectiveness in primary total knee arthroplasty (TKA). Methods A total of 94 patients (94 knees) with osteoarthritis underwent primary TKA between September 2010 and December 2011, whose data met the inclusion criteria and were retrospectively analyzed. A tourniquet was used in 51 cases (group A), no tourniquet in 43 cases (group B). There was no significant difference in gender, age, affected side, body mass index, preoperative hemoglobin (Hb) level, range of motion (ROM), visual analogue scale (VAS), Hospital for Special Surgery (HSS) score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) between 2 groups (P gt; 0.05). The data were compared between 2 groups, including hematocrit (Hct), Hb, hidden blood loss, dominant blood loss, theoretical total blood loss, the operation time, hospitalization days, increasing rate of circumference length above 10 cm of the knee, VAS score, ROM, HSS score, and WOMAC score. Results Four cases (7.84%) of group A and 1 case (2.33%) of group B received blood transfusions, showing no significant difference (χ2=1.410, P=0.235). There was no significant difference in the Hb and Hct between 2 groups at 2 days after operation (P gt; 0.05). The dominant blood loss of group A was significantly less than that of group B (P lt; 0.05), while the hidden blood loss of group A was significantly more than that of group B (P lt; 0.05), but there was no significant difference in theoretical total blood loss between 2 groups (t=0.662, P=0.510). The operation time, hospitalization days, and VAS score at 3 days showed no significant difference between 2 groups (P gt; 0.05). The wound healed by first intention after operation without related complication. At 3 days after operation, the increasing rate of circumference length above 10 cm of the knee in group A was significantly higher than that of group B (t=9.435, P=0.000), but no significant difference at 7 days (t=0.462, P=0.645). At 3 and 5 days after operation, the ROM values in group B were significantly larger than those of group A (P lt; 0.05), but no significant difference at 7 days (t= — 1.279, P=0.204). The patients were all followed up 12-18 months (mean, 14.3 months). There was no significant difference in the HSS score between 2 groups at 1 year after operation (t=0.952, P=0.344), but significant difference was found in the WOMAC score between 2 groups (t= — 2.488, P=0.015). The X-ray films showed that the prosthesis was in good position, without loosening, subsidence, or osteolysis. Conclusion Application of a tourniquet in TKA increases hidden blood loss, and there is no obvious advantage in reducing transfusion rate compared with the non-tourniquet group, so it is recommended to reduce the time and pressure of the tourniquet for patients with high-risk of thrombosis.