Since the era of total knee replacement (TKR) began in the late 1960s, total knee replacement has become one of the commonest operations in orthopaedic practice.

TKR is frequently associated with transfusion of allogenic blood Benoni G 1995; Seppo T 1997. In our centre, 30 % of patients who had undergone TKR received allogenc blood transfusion perioperatively. Although, serological screening has reduced the risk for viral infection to a very low levelKlein HG 1995; Schreiber GB 1996, the public is still concerned about this potential serious complication. Allogenic blood transfusion can be also associated with other non infectious complications such as haemolysis, immunosuppression, transfusion-related acute lung injury and even death.Madjdpour C 2005 Therefore, further refinement of strategies to avoid exposure to allogeneic blood is needed.

Amongst the technologies to minimise the need for blood transfusion is the use of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon amino-caproic acid (EACA).New Reference

Objectives: The purpose of this review is to investigate the evidence for the efficacy of Tranexamic acid in reducing peri-operative blood loss and blood transfusion after total knee replacement, and the evidence for any effect on clinical outcomes such as reduction in re-operation rates or increase in complication rates (e.g. deep venous thrombosis, pulmonary embolism, ischaemic heart diseases and mortality).

Method: Systematic review and metananalysis based on Cochrane guidelines of all randomised and quasirandomised trials.

Results: Fiften RCTs were included in the study; there has been a significant reduction of blood loss (P value 0.00001, I2 = 89%), blood transfusion without increase in systeanatic side effects such as ischaemic heart diseases, DVT, pulmondary embolisms. There was no singnificant difference in length of stay.

We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the effect of tranexamic acid (TXA) upon blood loss and transfusion in primary total knee replacement. The review used the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. A total of 19 trials were eligible: 18 used intravenous administration, one also evaluated oral dosing and one trial evaluated topical use. TXA led to a significant reduction in the proportion of patients requiring blood transfusion (risk ratio (RR) 2.56, 95% confidence interval (CI) 2.1 to 3.1, p < 0.001; heterogeneity I² = 75%; 14 trials, 824 patients). Using TXA also reduced total blood loss by a mean of 591 ml (95% CI 536 to 647, p < 0.001; I² = 78%; nine trials, 763 patients). The clinical interpretation of these findings is limited by substantial heterogeneity. However, subgroup analysis of high-dose (> 4 g) TXA showed a plausible consistent reduction in blood transfusion requirements (RR 5.33; 95% CI 2.44 to 11.65, p < 0.001; I² = 0%), a finding that should be confirmed by a further well-designed trial. The current evidence from trials does not support an increased risk of deep-vein thrombosis (13 trials, 801 patients) or pulmonary embolism (18 trials, 971 patients) due to TXA administration.

Aims. Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA. Patients and Methods. A total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS). Results. TKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs 158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs 661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs 1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA. Conclusion. For hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability. Cite this article: Bone Joint J 2019;101-B:1093–1099

The use of antifibrinolytic drugs and many other agents have a critical importance in bleeding control. Tranexamic acid [4- (aminomethyl) cyclohexanecarboxylic acid] is a synthetic amino acid lysine derivative with antifibrinolytic activity in humans. There are many studies in the literature that show that it is effective and effective both systemically and locally in spinal surgery. However, all of these studies have investigated the effects of topical tranexamic acid on bleeding and its effect on fusion has not been investigated yet. Aim of this study is to investigate the effect of topical tranexamic acid on fusion using macroscopic, radiologic and microscopic techniques. After approve of ethics committee with the protocol number 19/2019 for 28 Wistar Albino rats underwent intertransvers fusion. All rats were randomized into four (4) groups, using sealed envelopes. Local tranexamic acid (Transamin® 100 mg/ml, Teva İlaç, İstanbul) doses was determined based on previously conducted studies; 1mg/kg (D1 group), 10mg/kg (D10 group), 100 mg/kg (D100 group) and no tranexamic acid (D0 group). At the end of 8. th. weeks all rats were evaluated with manuel palpation, mammography and histopathologic analysis. Radiographic examination was performed two times to evaluate the intra and inter observer differences. 2 rats in-group D0 died after the radiographic examination. Assessment of fusion with manual palpation revealed that use of local 1mg / kg tranexamic acid had no effect on fusion (p=0.32), however with increasing doses of tranexamic acid had negative effect on fusion (p=0.002). On radiologic examination, spearman's rho correlation coefficient was found to be moderate in the first evaluation (r=0.46) and high in second evaluation (r=0.61). Radiological examination revealed that the control group was the best in fusion (p=0.007), and that tranexamic acid affected fusion adversely, independent of dosage (p=0.27). Among the groups in histopathologic examination, no statistical difference was found (p=0.134). Local administration of tranexamic acid affects the intertransverse fusion adversely depending on the dosage macroscopically and it also affects fusion adversely independent of the dosage radiologically and histopathologically

Introduction and Aims: Decreasing blood loss during total hip replacement (THR) remains a challenge for the orthopaedic surgeon. This study investigated the effects of the antifibrinolytics aprotinin and epsilon aminocaproic acid (EACA) against placebo on blood loss during primary total hip replacement. Their safety and mechanism of action was also investigated. Method: Forty-five patients undergoing primary unilateral total hip arthroplasty were randomised to receive an infusion of either aprotinin, EACA, or placebo. Intra- and post-operative blood loss was measured, as was the rate of blood transfusion and changes in haemoglobin concentration. Clinical examination and duplex ultrasound was used in all patients to detect thrombotic events. All patients were assessed clinically six weeks post-op to detect adverse events. Platelet function was assessed using P-selectin, Platelet-monocyte aggregates (PMA) and factor V/Va levels. D-dimer activity was recorded as an indicator of fibrinolysis. Non-parametric statistical analysis was employed in the interpretation of results. Results: There was no difference in demographics or pre-operative platelet function between the groups with the exception of the EACA group which had a lower pre-operative haemoglobin concentration. Intra-operative blood loss was significantly lower in the aprotinin group compared to placebo (p=0.01), similarly there was also a reduction in intra-operative blood loss in the EACA group but this did not reach statistical significance. Post-operative bleeding from closed suction drains was markedly reduced for both aprotinin (60%, p=< 0.01) and EACA (53%, p=< 0.001) compared to placebo. Markedly less haemoglobin was lost in drains in both antifibrinolytic groups, with aprotinin showing a 77% (p=< 0.0001) and EACA a 73% reduction (p=< 0.001) in post-operative haemoglobin loss. Despite this, no difference in the rate of blood transfusion was observed between groups. Total hip arthroplasty surgery led to the activation of platelets as evidenced by P-selectin, PMA and factor V/Va levels. However, platelet function was not affected by either aprotinin or EACA. Both antifibrinolytics showed a similar increase in D-dimer levels indicating a similar efficacy in inhibiting fibrinbolysis. There were no DVTs, PEs or infections recorded in the study, and no increase in adverse events was seen with the use of antifibrinolytics. Conclusion: Infusion of either aprotinin or EACA reduces blood loss after primary THA. Both agents are equally effective and have a favourable safety profile. The two drugs inhibit fibrinolysis in a similar fashion, and this action appears to be independent of platelets

Purpose. To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching. Methods and Results. Retrospective review of 50 consecutive adult scoliosis patients treated using anterior only(14,28%), posterior only(19,38%) or combined(17,34%) approaches. All patients were anaesthetised by the same anaesthetist implementing a standard protocol using cell salvage, controlled hypotension and antifibrinolytics. Mean age was 24.6 years. BMI was 21.9. On an average 9.5(6-15) levels were fused, with an average duration of surgery of 284.6(130-550) minutes. Antifibrinolytics were used in 31(62%) of the patients which included Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Patients on antifibrinolytics had a significantly (p<0.05) lower blood loss (530ml) as compared to other patients (672ml). Mean volume of the cell saved blood re-transfused was 693.8 ml and mean postoperative HB level dropped to 10.7 g/dl(7.7-15) from a mean preoperative of 13.3 g/dl(10-17). 7(42%) with combined approaches and 3(15.8%) with posterior only approach required blood transfusion, 4/50(8%) of which required intra while 6/50(12%) required intra and postoperative transfusion. None of the patients having anterior surgery alone required blood transfusion. Conclusion. Use of antifibrinolytics reduces the need for blood transfusion in scoliosis surgery. For anterior surgery alone, we do not cross match

Tranexamic acid (TXA) is an inexpensive antifibrinolytic. Currently there are no national guidelines in the UK that promote the use of TXA in femoral fragility fracture (FFF) management. The aim of the study was to determine whether intra-operative intravenous TXA affects the requirement for post-operative blood transfusion following FFF surgery. A prospective non-randomized case-control study of consecutive FFF admitted to the study centre was performed. 361 patients were included in the study (mean age 81.4yrs; mean BMI 23.5; 73.7% female). TXA was given at the discretion of the operating surgeon, with 178 (49%) patients receiving TXA. Patient demographics, surgical management, peri-operative haemoglobin (Hb) and haematocrit, intravenous TXA use, and requirement for blood transfusion were recorded prospectively. Percentage fall in Hb from preoperative level was calculated at postoperative day one. Calculated-blood-loss (CBL) was determined using the Nadler and Gross formulae. The groups were well matched in terms of patient demographics, injury types and surgical management. The requirement for postoperative blood transfusion was significantly reduced in the TXA group: 15/178 (8.4%) compared to 58/183 (31.7%) (p<0.001; Chi square). TXA significantly reduced both the percentage fall in Hb (mean difference 4.3%, p<0.001) and the CBL (mean difference -222ml, p<0.001). There was no difference in venous thrombosis embolism events between the groups. Intra-operative intravenous TXA during the surgical management of FFF significantly reduced rate of transfusion, CBL and the percentage drop in HB

Aims. Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol. Patients and Methods. A multicentre, prospective, randomized, double-blind, placebo-controlled trial was undertaken involving 229 patients undergoing primary cementless THA using a posterior approach, whose extended rivaroxaban thromboprophylaxis started on the day of surgery. There were 98 male and 131 female patients, with a mean age of 65.5 years (32 to 91). The primary outcome, perioperative RBL, was evaluated at 72 hours postoperatively. The efficacy of short- and long-TXA protocols in the reduction of perioperative RBL was compared with a placebo group. Results. TXA significantly reduced perioperative blood loss compared with placebo (p < 0.001); the mean differences were 525.3 ml (short-TXA vs placebo) and 550.1 ml (long-TXA vs placebo). No venous or arterial thromboembolic complications were reported. The upper boundary of the 95% confidence interval, when comparing short and long protocols, was below the pre-specified margin of non-inferiority (p = 0.027). Conclusion. In patients undergoing primary cementless THA, using a posterior approach, who are treated with rivaroxaban for thromboembolic prophylaxis, short- and long-TXA IV protocols are significantly more effective than placebo in reducing perioperative RBL, without any thromboembolic complications. Non-inferiority of a short- versus a long-TXA protocol in reducing perioperative RBL was supported in a secondary analysis

Despite advances in contemporary hip and knee arthroplasty, blood loss continues to be an issue. Though blood transfusion has long been used to treat post-operative anemia, the associated risks are well established. The objective of this article is to present two practical and effective approaches to minimising blood loss and transfusion rates in hip and knee arthroplasty: the use of antifibrinolytic medications such as tranexamic acid and the adoption of more conservative transfusion indications

Objectives. Tranexamic acid (TXA) is an antifibrinolytic agent used as a blood-sparing technique in total knee arthroplasty (TKA), and is routinely administered by intravenous (IV) or intra-articular (IA) injection. Recently, a novel method of TXA administration, the combined IV and IA application of TXA, has been applied in TKA. However, the scientific evidence of combined administration of TXA in TKA is still meagre. This meta-analysis aimed to investigate the efficacy and safety of combined IV and IA TXA in patients undergoing TKA. Materials and Methods. A systematic search was carried out in PubMed, the Cochrane Clinical Trial Register (Issue12 2015), Embase, Web of Science and the Chinese Biomedical Database. Only randomised controlled trials (RCT) evaluating the efficacy and safety of combined use TXA in TKA were identified. Two authors independently identified the eligible studies, extracted data and assessed the methodological quality of included studies. Meta-analysis was conducted using Review Manager 5.3 software. Results. A total of ten RCTs (1143 patients) were included in this study. All the included studies were randomised and the quality of included studies still needed improvement. The results indicated that, compared with either placebo or the single-dose TXA (IV or IA) group, the combination of IV and IA TXA group had significantly less total blood loss, hidden blood loss, total drain output, a lower transfusion rate and a lower drop in haemoglobin level. There were no statistically significant differences in complications such as wound infection and deep vein thrombosis between the combination group and the placebo or single-dose TXA group. Conclusions. Compared with placebo or the single-dose TXA, the combined use of IV and IA TXA provided significantly better results with respect to all outcomes related to post-operative blood loss without increasing the risk of thromboembolic complications in TKA. Cite this article: Z. F. Yuan, H. Yin, W. P. Ma, D. L. Xing. The combined effect of administration of intravenous and topical tranexamic acid on blood loss and transfusion rate in total knee arthroplasty: combined tranexamic acid for TKA. Bone Joint Res 2016;5:353–361. DOI: 10.1302/2046-3758.58.BJR-2016-0001.R2

Introduction: The intra-operative blood-loss data on scoliosis surgery patients at Dunedin Hospital during 1992–2000 were analysed retrospectively. Various measures had been tried to reduce the intra-operative blood loss and included use of fibrinogen, DDAVP and antifibrinolytic agents. Patients with medical abnormalities, particularly those with muscular dystrophies/myopathies appeared to have a high incidence of intra-operative blood loss. Aim: To evaluate the amount of bleeding. any pre-operative factors identifiable as contributing to the bleeding and any preventive measures which have been identified. Methods: An audit of intra-operative blood loss on all cases presented for corrective surgery for scoliosis in Dunedin Hospital during the period 1992–2000 was undertaken. Results: A total of 160 operations were performed during the eight years. The mean age of the cohort was 14.8 years (SD 6.8) and the mean weight of the cohort was 44kg (SD 18.9). Fifty-six percent of the patients were idiopathic cases with no medical abnormalities, where as 44% had congenital/medical abnormalities. The mean blood loss as a percentage of calculated blood volume was 38% (SD 35). There was a strong suggestion that patients with medical abnormalities, particularly those with muscular dystrophies, had much higher blood losses (63%, SD 59). There were no differences between the different patient groups in the pre-operative haematological investigations. Conclusions: We have noted a definite overall improvement in the amount of blood loss since 1995. The reasons included intra-operative monitoring of coagulation factors, early use of fibrinogen, use of DDAVP and antifibrinolytic agents

Tranexamic Acid (TXA) is widely used to decrease bleeding by its antifibrinolytic mechanism. Its use is widespread within orthopaedic surgery, with level one evidence for its efficacy in total hip and knee replacement surgery; significantly reducing transfusion rates without increased thromboembolic disease. There is limited evidence for its use during hip fracture surgery, and we therefore sought to investigate its effects with a prospective cohort study. We recorded intra-operative blood loss, pre and post-operative haemoglobin and creatinine levels, post-operative complications and mortality in all hip fracture patients over a six month period. During this time, we introduced one gram of TXA into our standardised hip fracture theatre checklist. It was subsequently given to all patients unless contra-indicated. A total of 99 patients were included. 90-day mortality in the control group was 16%, there was no mortality in the TXA group (p<0.05). 14 patients required a transfusion in the control group and 3 in the TXA group (19% vs 11% transfusion rate, 0.36 units RCC vs 0.22 per patient respectively) Mean blood loss was 338 vs 235mls, Haemoglobin drop 23 vs 18g/dl control and TXA groups respectively. We have demonstrated a significantly lower mortality rate with TXA. We have also shown lower rates of transfusion, blood loss and recorded haemoglobin drop with the use of TXA. We intend to continue this study to demonstrate this significantly, and fully clarify the safety profile of TXA in this frail cohort of patients

Total hip and knee arthroplasty is known to have a significant blood loss averaging 3–4 g/dL. Historically, transfusion rates have been as high as 70%. Despite years of work to optimise blood management, some published data suggests that transfusion rates (especially with allogeneic blood) are rising. There is wide variability between surgeons as well, suggesting that varying protocols can influence transfusion rates. Multiple studies now associate blood transfusions with negative outcomes including increased surgical site infection, costs, and length of stay. Preoperative measures can be employed. Identify patients that are at increased risk of blood transfusion. Smaller stature female patients, have pre-operative anemia (Hgb less than 13.0 gm/dl), or are undergoing revision or bilateral surgery are at high risk. We identify these patients and check a hemoglobin preoperatively, using a non-invasive finger monitor for screening. For anemic patients, iron administration (oral or IV) can be given, along with Procrit/Epogen in select cases. Insurance coverage for that medication has been challenging. Intraoperative measures that have been linked to reduced postoperative transfusions include regional anesthesia and intraoperative hypotension (mean arterial pressure <60mm/hg). Lowering the surgical time by practicing efficient, organised, and quality surgery, along with leaving a dry field at the completion of surgery can reduce blood loss. Tranexemic acid (TXA) is an antifibrinolytic agent that has been shown to be effective, reducing average blood loss by 300 cc per case. There are multiple different administration protocols: IV using either a weight-based dosing 10–20 mg/kg or standardised dosing for all patients. Our current regimen is 1 gm IV preoperatively, 1 gm IV in PACU. Topical TXA can be used, usually 2–3 gm mixed in 50–100 cc of saline, sprayed in wound and allow to soak for 3–5 minutes. Oral administration is attractive for ease of use and reduced cost, standard oral dosing is 1950 mg PO 2 hours prior to surgery. The American Association of Hip and Knee Surgeons, in collaboration with the American Association of Orthopedic Surgeons, American Society of Regional Anesthesiologists, and the Hip & Knee Society have developed a Clinical Practice Guideline with 8 recommendations for TXA as follows: All individual formulations are effective at reducing blood loss – strong; No method of administration is clearly superior at reducing blood loss and the risk of transfusion; The dose of IV or topical TXA does not significantly affect the drug's ability to reduce blood loss and risk of transfusion; Multiple doses of IV or oral TXA compared to a single dose does not significantly alter the risk of blood transfusion; Pre-incision IV TXA administration potentially reduces blood loss and risk of transfusion compared to post-incision administration; Administration of all TXA formulations in patients without history of VTE does not increase the risk of VTE; Administration of all TXA formulations in patients with a history of VTE, MI, CVA, TIA, or vascular stent does not appear to increase the risk of VTE; Administration of all TXA formulations does not appear to increase the risk of arterial thrombotic events; Postoperative measures to reduce transfusion rates include changing transfusion triggers. Instead of treating a “number”, use lower thresholds and employ safe algorithms established. In conclusion, a comprehensive blood management program can reduce transfusion rates to less than 3% for THA and 1% for TKA and facilitate outpatient total joint arthroplasty

Background. Tranexamic acid is an antifibrinolytic drug that has been shown to successfully reduce postoperative blood loss in total knee and hip arthroplasty. However, the efficacy of TXA following total shoulder arthroplasty has not been reported. Purpose. The purpose of the present study was to evaluate the impact of intravenous TXA on postoperative blood loss and transfusion rates in total shoulder reconstruction. Methods. Between July and December 2014, 50 patients scheduled for primary total shoulder arthroplasty of the shoulder were included in this blinded, randomized study. Patients received either 1000mg intravenous TXA within thirty minutes before skin incision and another 1000mg intravenously administered TXA during wound closure (group 1), or a placebo (group 2). The perioperative blood loss and the rate of blood transfusions were analyzed. Results. Early postoperative blood loss was 80.0±105.5ml in the TXA group (group 1), and 202.1±195.8ml in the placebo group (group 2). The administration of blood products was not necessary during the study period. Conclusion. The administration of intravenous tranexamic acid significantly reduced the postoperative blood loss following total shoulder arthroplasty

Tranexamic acid (TXA) is an antifibrinolytic that can prevent clot breakdown. Trauma patients often have coagulopathy which can cause mortality due to bleeding. The purpose of this review is to investigate the efficacy of TXA in reducing mortality in major trauma and secondly to look at patient's outcomes when using TXA in trauma. Searches were performed in PUBMED, EMBASE and other databases for randomised controlled trials (RCT) and observational studies. The author searched for all relevant evidence on the use of TXA in major trauma. Relevant studies were assessed for quality using the Cochrane's Collaboration's tool for assessing risk of bias. Eight relevant studies were identified from the search, 3 randomised controlled trials (RCTs) and 5 observational studies were identified. Five of the 8 studies found a significance in mortality with TXA use. Three showed TXA reduced mortality including the high quality level I evidence, CRASH 2 study. Three studies found no significance on mortality. There appears to be no increased risk of VOE with TXA however results from the studies varied. No study reported any adverse events due to TXA use. There does not appear to be any significant benefit of TXA use in TBI but a trend towards lower mortality. There is a role in paediatric trauma despite evidence from only 2 observational studies. There is a high quality RCT to suggest the use of TXA in trauma patients with supporting evidence from observational studies. The outcomes in TBI are unclear. It may be beneficial in paediatric use but there is currently no level 1 evidence in paediatrics to support this. Further prospective studies looking specifically at role in TBI and paediatric trauma are required to support routine use in these specific populations

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic, and long bone fractures; interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews; and pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews

Perioperative blood conservation remains an important topic today in order to reduce complications, improve function, and facilitate recovery after a total knee replacement (TKR). Studies have shown that the degree of postoperative anemia is related to an increase in complications. A greater blood loss and need for transfusion is associated with a higher risk of infection, a slower recovery process, increased morbidity to patients, as well as an increased cost to the health care system. Typical blood loss estimates range from 800cc to over 1700cc, when accounting not only for intraoperative but postoperative blood loss. Several strategies have been developed to help mitigate the risk of perioperative blood loss and need for subsequent transfusion. Firstly, preoperative measures such as vitamin and mineral supplementation can ensure the starting hemoglobin and red cell count are maximised. Additionally, erythropoietin can be helpful in refractory cases of preoperative anemia. Preoperative autologous blood donation was used extensively in the past, but has fallen out of favor due to its inefficiency and cost. Intraoperatively, measures such as the use of a tourniquet, meticulous technique, and expeditious surgery can help reduce blood loss. The most effective method, however, has been the use of tranexamic acid (TXA). TXA, an antifibrinolytic compound, has been extremely effective at reducing perioperative blood loss without increasing the risk of thromboembolic events. TXA can be used topically or intravenously. Other methods that can reduce intraoperative blood loss include the use of fibrin sealants, applied to the soft tissues and bony surfaces around the knee. Postoperatively, the avoidance of wound drains is associated with a higher blood count and reduced transfusion risk. Alternatively, drainage reinfusion systems can be used to raise the postoperative blood count, particularly in cases of bilateral TKR

Tranexamic acid (TEA), an antifibrinolytic agent, is routinely used for reduction of blood loss in total hip arthroplasty (THA). However, use of intravenous (IV) TEA has been questioned due to safety concerns and a lack of biochemical data in the arthroplasty literature. Tranexamic acid given topically as a periarticular solution is a promising alternative route of administration. The purpose of this study is to identify differences in systemic absorption for intravenous and topical TEA administered during primary THA. In a blinded randomised controlled trial of patients undergoing primary cementless total hip arthroplasty, 29 participants received a weight-based bolus infusion of intravenous TEA (20 mg/kg) 10 minutes prior to skin incision. Conversely, 15 participants received a 1.5 g bolus dose of TEA administered topically into the periarticular region of the operative hip at the time of arthrotomy closure. A blood sample was drawn one hour post-administration for measurement of serum TEA concentration (µg/mL) by tandem mass spectrometry. In addition to comparing mean concentration levels for both treatment arms, each sample concentration was referenced to a pre-determined TEA concentration threshold of 10 µg/mL, a value known to represent 80% tissue plasminogen activator (tPA) inhibition in vivo. Those participants receiving topical TEA had four-fold lower TEA levels at one hour postoperatively (mean 12.44 ± 17.59 versus 52.54 ± 23.94 µg/mL, p<0.05). These results demonstrate significantly lower circulating TEA at one hour after topical administration. Intravenous TEA must travel through the intravascular compartment in order to reach the operative hip. Topical administration of TEA targets bleeding tissues within the surgical field without necessitating parenteral administration. This results in less inhibition of tPA away from the operative site, potentially decreasing the risk of developing a pro-thrombotic state postoperatively. Correlating these results with outcomes from clinical efficacy trials comparing intravenous and topical TEA use in THA will further clarify optimal dosing strategies

Despite improvements in surgical technique, blood loss continues to be an issue following TJR in 2013. Peri-operative blood loss averages between 1000 and 1500 cc during THR and TKR. Multiple methods have been employed in attempts to minimise this loss. Concepts such as hypotensive anesthesia, tourniquet use, intraoperative blood salvage and autologous pre-donation and postoperative re-infusion drains as well as the use of bipolar sealants, fibrin sprays and thrombin agents have been tried with varying degrees of success. Recently there has been a surge of interest in the use of antifibrinolytics such as Tranexamic Acid (TXA), Aprotinin and Aminocaproic Acid. These medications have a long history of use in other fields such as cardiac and oral surgery but are just recently being utilised following TJR. Of these medications, TXA has been by far the best studied. TXA is a synthetic amino acid that inhibits fibrinolysis by competitively and reversibly blocking the Lysine binding sites on plasminogen. This inhibits its activation and slows the conversion from plasminogen to plasmin and this prohibits the binding of plasmin to fibrin and the subsequent dissolving of clot formation. TXA can be used either topically or intravenously and there are more than 50 clinical papers that have evaluated the effectiveness of TXA in TJR. There is abundant scientific data to support its safety with minimal increased risk of thrombosis and its use should be considered as a safe, effective and economical means of reducing blood loss in TJR in 2013

Perioperative blood conservation remains an important topic today in order to reduce complications, improve function, and facilitate recovery after a total knee replacement (TKR). Studies have shown that the degree of postoperative anemia is related to an increase in complications. A greater blood loss and need for transfusion is associated with a higher risk of infection, a slower recovery process, increased morbidity to patients, as well as an increased cost to the healthcare system. Typical blood loss estimates range from 800cc to over 1700cc, when accounting not only for intraoperative but postoperative blood loss. Several strategies have been developed to help mitigate the risk of perioperative blood loss and need for subsequent transfusion. Firstly, preoperative measures such as vitamin and mineral supplementation can ensure the starting hemoglobin and red cell count are maximised. Additionally, erythropoietin can be helpful in refractory cases of preoperative anemia. Preoperative autologous blood donation was used extensively in the past, but has fallen out of favor due to its inefficiency and cost. Intraoperatively, measures such as the use of a tourniquet, meticulous technique, and expeditious surgery can help reduce blood loss. The most effective method, however, has been the use of tranexamic acid (TXA). TXA, an antifibrinolytic compound, has been extremely effective at reducing perioperative blood loss without increasing the risk of thromboembolic events. TXA can be used topically or intravenously. Other methods that can reduce intraoperative blood loss include the use of fibrin sealants, applied to the soft tissues and bony surfaces around the knee. Postoperatively, the avoidance of wound drains is associated with a higher blood count and reduced transfusion risk. Alternatively, drainage reinfusion systems can be used to raise the postoperative blood count, particularly in cases of bilateral TKR