Background. Total joint replacement surgery is associated with large amounts of blood loss and significant rates of transfusions. Postoperative bleeding is one of the most important problems after major orthopedic surgeries including revision Total Hip Arthroplasty (THA). It has been demonstrate that Tranexamic acid is a useful agent to control the volume of blood loss. However, the more effective route of TXA administration remained controversial. Methods. In current study, we compared the effects of local and intravenous(IV) administration of TXA on need to blood transfusion and hemoglobin drop. We randomized 80 patients undergoing revision THA into two groups: local group and IV group. In group IV 40 patients was administrated TXA 4 g alone systemically and in local group 40 patients the joint was irrigated with 4 g of TXA plus 0.33mg DEP (1:200,000). Results. The level of Hb was measured before and after operation and the rate of Hb drop was compared. Also, the blood transfused were compared in two group. Results showed topical TXA plus DEP substantially reduced total blood loss, hidden blood loss and transfusion rate compared with TXA alone, without increasing the risks of hemodynamic complexity. Conclusion. We conclude that local use of TXA plus DEP was crucially effective and safe option compared with intravenous TXA alone in reducing total and hidden blood loss and transfusion rate following revision THA without considerable complications

Abstract. By next summer the number of patients in the tranexamic acid group will be much higher, probably around 50–60. Purpose. Tranexamic acid has been extensively studied in single total knee and total hip replacement patients. It has been found to reduce blood loss and transfusion rates, with no increase in the rate of venous thromboembolism. This study was undertaken to determine whether tranexamic acid reduces blood loss and the rate of blood transfusion after bilateral total knee replacement, which has a much higher transfusion rate. Method. The preoperative haemoglobin and the lowest postoperative haemoglobin for 30 consecutive bilateral tkr patients who received tranexamic acid was recorded. These were compared with a a consecutive series of 262 historic controls that did not receive tranexamic acid. All patients were operated on by the same surgeon. The surgical procedure was essentially unchanged throughout the study period. The decision to transfuse was made by the hospitalist, who did not know whether the patient received tranexamic acid. Data calculated included the percentage drop in haemoglobin, and the transfusion rate for each group. A subset of patients who were anaemic preoperatively (Hb < 125) were compared for each group. Results. For the control group, which did not receive tranexamic acid, the average preoperative haemoglobin was 138, and dropped to 85 postoperatively. This represented a 38% drop in haemoglobin. Of the 262 patients, 105 required transfusion, giving a transfusion rate of 40%. The average number of units transfused was 1.8. For the study group, which received tranexamic acid, the average preoperative haemoglobin was 133, and dropped to 97 postoperatively. This represented a 27% drop in haemoglobin. Of the 30 patients, only one required transfusion, giving a transfusion rate of 4%. That one patient required only one unit of blood. For the patients who were anaemic preoperatively (Hb < 125) the transfusion rate for the control group was 97%, and for the study group was 20% (1/5). Conclusion. Tranexamic acid markedly reduces blood loss and the rate of transfusion for patients undergoing bilateral total knee replacement

Purpose. Topical application of tranexamic acid (TXA) to bleeding wound surfaces reduces blood loss in patients undergoing some major surgeries, without systemic complications. The objective of this study was to determine if TXA applied topically reduced postoperative bleeding and transfusion rates after primary total hip arthroplasty (THA) and primary bipolar hemiarthroplasty (BA). Methods. We retrospectively compared 77 patients undergoing hip arthroplasty surgery in which tranexamic acid was routinely used, to a group of 70 patients from a similar time frame prior to the introduction of tranexamic acid use. In the former group 40 patients had THA and 37 patients BA; in the latter group 35 patients underwent THA and 35 patients BA. In both THA and BA, the joint was bathed in TXA solution (at a concentration of 3.0 g TXA per 100 mL saline) at three points during the procedure. The primary outcome was blood loss calculated from the difference between the preoperative hemoglobin level and the corresponding lowest postoperative value or hemoglobin level prior to transfusion. Results. Postoperative transfusions decreased significantly with TXA, dropping from 50.0% to 27.5%, and from 63% to 48%, in the THA and BA groups, respectively. We also found significant reductions in hemoglobin loss and blood loss of 8 g/dL and 336 mL respectively for THAs and 6 g/dL and 176 mL respectively for BAs following the introduction of tranexamic acid. There was no difference in the rates of deep-vein thrombosis or pulmonary embolism between the two groups. Discussion and Conclusion. Topical application of TXA significantly reduces postoperative blood loss and transfusion risk in THA and BA, with no clinically important increase in complications being identified

Background:. Role of intra-articular Tranexamic acid in total knee replacement arthroplasty. Materials and methods. Prospective evaluation was done to see the effect of intra-articular Tranexamic acid on blood loss in 60 patients (120 knees) undergoing total knee arthroplasty. All the patients were operated by one surgeon with same technique by using same implants. Patients were randomly injected 1500 mg/20 ml of Tranexamic acid on one side of the knee only. Nothing was injected on the contra lateral knee. Evaluation was done for swelling and the amount of blood loss in the drain. Results:. Average blood loss in the drain on Tranexamic side was 140 ml and the opposite side was 390 ml. Swelling was more observed on the non Tranexamic side. Average time for drain removal on Tranexamic side was 36 hours while it was 48 hours on non Tranexamic side. Early mobilization and weight bearing was less painful in Tranexamic side. No patient had systemic complications of Tranexamic acid. Conclusion:. Intra-articular injection of Tranexamic acid reduces blood loss, swelling around the knee without systemic side effects and allows early weight bearing and mobilization of the joint

Background. Tourniquets and tranexamic acid (TXA) are commonly used in total knee arthroplasty (TKA), but there is not consensus on how these interventions affect blood transfusion rates and total blood loss. Few studies examine the combined use of both interventions. We compared outcome measures and transfusion rates following TKA, with and without the use of tourniquet and TXA. Methods. Retrospective cohort study of 477 consecutive patients undergoing primary TKA at a single center between 2008 and 2013. There were 243 in the tourniquet-assisted (TA) and 234 in the tourniquet-unassisted (TU) group. Subanalysis was performed on those patients receiving TXA. Results. Mean operative duration was 66.4 minutes (30–135) in the TA group and 87.5 minutes (43–162) in the TU group (p<0.0001). Mean post-operative drop in hemoglobin was significantly greater in TU group (3.1g/dl vs. 2.8g/dl, p=0.002). The transfusion rate was 9.5% in TA compared to 11.5% in TU patients (p=0.46) with comparable mean units transfused (2.6 vs. 2.2, p=0.30). There was no significant difference in rate of wound infection (2% vs. 1.7%, p = 0.82) and total complication rate (4.1% vs. 2.5%, p=0.19) between groups. Mean length of stay was 5.8 days in TA and 7 days in the TU group (p=0.07). Those patients given TXA had a lower hemoglobin drop (2.6g/dl vs. 3.3g/dl, p=0.04) with similar transfusion (10.9% vs. 13.3%, p=0.61) and complication (3.3% vs. 5.2%, p=0.95) rates. Discussion. Tourniquet-unassisted TKA had a greater operative duration and post-operative drop in hemoglobin than tourniquet-assisted TKA. However, transfusion rates were similar between groups. TXA use reduced the operative decrease in hemoglobin with no effect on complication or transfusion rates. Key words. TKA, tourniquet, tranexamic acid, transfusion rates, outcomes. For any figures or tables, please contact authors directly

Background. The reductions of perioperative blood loss and inflammatory response are important in total knee arthroplasty. Tranexamic acid reduced blood loss and the inflammatory response in several studies. However, the effect of epinephrine administration plus tranexamic acid has not been intensively investigated, to our knowledge. In this study, we evaluated whether the combined administration of low-dose epinephrine plus tranexamic acid reduced perioperative blood loss or inflammatory response further compared with tranexamic acid alone. Methods. This randomized placebo-controlled trial consisted of 179 consecutive patients who underwent primary total knee arthroplasty. Patients were randomized into 3 interventions: Group IV received intravenous low-dose epinephrine plus tranexamic acid, Group TP received topical diluted epinephrine plus tranexamic acid, and Group CT received tranexamic acid alone. The primary outcome was perioperative blood loss on postoperative day 1. Secondary outcomes included perioperative blood loss on postoperative day 3, coagulation and fibrinolysis parameters (measured by thromboelastography), inflammatory cytokine levels, transfusion values (rate and volume), thromboembolic complications, length of hospital stay, wound score, range of motion, and Hospital for Special Surgery (HSS) score. Results. The mean calculated total blood loss (and standard deviation) in Group IV was 348.1 ± 158.2 mL on postoperative day 1 and 458.0 ± 183.4 mL on postoperative day 3, which were significantly reduced (p < 0.05) compared with Group TP at 420.5 ± 188.4 mL on postoperative day 1 and 531.1 ± 231.4 mL on postoperative day 3 and Group CT at 520.4 ± 228.4 mL on postoperative day 1 and 633.7 ± 237.3 mL on postoperative day 3. Intravenous low-dose epinephrine exhibited a net anti-inflammatory activity in total knee arthroplasty and did not induce an obvious hypercoagulable status. Transfusion values were significantly (p=0.023 and 0.032) reduced in Group IV, but no significant differences were observed in the incidence of thromboembolic complications, wound score, range of motion, and HSS score among the 3 groups (p > 0.05). Conclusions. The combined administration of low-dose epinephrine and tranexamic acid demonstrated an increased effect in reducing perioperative blood loss and the inflammatory response compared with tranexamic acid alone, with no apparent increased incidence of thromboembolic and other complications

A prospective, randomized, double-blind study was done on 50 patients undergoing primary cementless total hip arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements. 50 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the incision. The intraoperative and postoperative blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Hemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively. Patients receiving tranexamic acid had a mean intraoperative blood loss of 410 ml (range, 300–510 ml) versus 615 ml (range, 515–750ml) (p value<0.05) in patients receiving placebo, a postoperative blood loss of 210 ml(range, 150–325ml) versus 490 ml(range, 370–540ml) (p value<0.05), and a total need for 8 blood transfusions versus 30. Only 6 out 25 patients in tranexamic acid group required blood transfusion whereas 18 out of 25 patients in the placebo group required transfusion. In the group receiving placebo the mean fall in hemoglobin was 2.9g/dl (range, 2.5–3.2) and in the group treated with tranexamic acid 1.6 g/dl (1.3–2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day. Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces peroperative and postoperative and total blood loss, and transfusion requirements in primary cementless total hip replacement surgery without any increased risk of thrombus formation

A prospective, randomized, double-blind study was done on 50 patients undergoing primary cementless total hip arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements. 50 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the incision. The intraoperative and postoperative blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Haemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively. Patients receiving tranexamic acid had a mean intraoperative blood loss of 410 ml (range, 300-510 ml) versus 615 ml (range, 515-750ml) (p value<0.05) in patients receiving placebo, a postoperative blood loss of 210 ml(range, 150-325ml) versus 490 ml(range,370-540ml) (p value<0.05), and a total need for 8 blood transfusions versus 30. Only 6 out 25 patients in tranexamic acid group required blood transfusion whereas 18 out of 25 patients in the placebo group required transfusion. In the group receiving placebo the mean fall in haemoglobin was 2.9g/dl (range, 2.5-3.2) and in the group treated with tranexamic acid 1.6 g/dl (1.3-2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day. Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces peroperative and postoperative and total blood loss, and transfusion requirements in primary cementless total hip replacement surgery without any increased risk of thrombus formation

The effectiveness of intravenous tranexamic acid (TA) in reducing blood loss and transfusion requirements during total hip replacement (THR) is well recognised. The aim of this study was to assess the effectiveness of a fibrin sealant in comparison to intravenous TA and a control group. We prospectively studied 270 patients with primary hip osteo-arthritis who underwent a straight forward THR between February 2012 and September 2013. The first 70 patients acted as the control group. The next 100 consecutive patients received fibrin sealant spray before closure and the last 100 patients received 1g TA on induction. Demographic data, comorbidities, surgical time, surgeon grade, anaesthetic type, haemoglobin drop post-operative and transfusion requirements were analysed using one-way ANOVA. The demographic characteristics, surgical time, surgeon grade, anaesthetic type and pre-operative haemoglobin of the 3 groups were comparable. Both fibrin sealant and intravenous TA were effective in reducing blood loss during THR (15%, p = 0.04 & 22.5%, p = 0.01, respectively), when compared to the control group. However, neither treatment was found to be superior to the other in preventing blood loss p = 0.39. Tranexamic acid was superior to fibrin sealant in decreasing allogeneic transfusion requirements (0% vs 10%, p = 0.05). The LOS was significantly shorter in the tranexamic acid group than fibrin sealant group and in the fibrin sealant group compared with control group. There was no significant difference between the groups with regards to proportion of patients with wound leaking problems. No other complications (e.g. VTE) were encountered. Both fibrin sealant and intravenous tranexamic acid were effective in reducing blood loss. However, tranexamic acid use reduced post-operative transfusion requirements

Total joint arthroplasty is one of the most common procedures performed in orthopaedic surgery. Over 600,000 total hip and total knee replacements are performed in the United States each year. At our 550 bed tertiary care facility, 437 total knee arthroplasties were performed in 2010 and 426 in 2011. Tranexamic acid is an antifibrinolyic synthetic derivative of aminocaproic acid used to prevent hemorrhage in patients undergoing surgical procedures. Several studies show decreased blood loss in patients receiving both intravenous and topical tranexamic acid. Beginning in 2011, our surgeons began using topical tranexamic acid in an irrigation solution of 3 grams in 100 mL of normal saline after implant placement and prior to closure of the incision. Our study is a retrospective review comparing patients receiving total knee arthroplasties before and after the institution of tranexamic acid. The purpose of our study was to assess estimated perioperative blood loss, determining the cost effectiveness of using tranexamic acid while comparing adverse effects of using topical tranexamic acid in total knee arthroplasty. Our study includes 683 primary total knees, 373 that received did not receive topical tranexamic acid and 310 that did, from January 1, 2010 to October 31, 2011. There were no demographic differences between the 2 groups. Topical tranexamic acid significantly (p<0.0001) decreased blood loss in patients receiving primary total knee arthroplasties. There were no differences between groups in thromboembolic events or joint infections. Tranexamic acid significantly (p<0.0001) decreased both blood bank cost and total cost of stay resulting in nearly $1,500 savings per patient to our institution

The effect of intra-articular tranexamic acid on blood loss in concurrent bilateral total knee arthroplasty was studied in 60 patients in double blind fashion; one knee receiving tranexamic acid, the other knee receiving physiological saline acting as control. A single surgeon performed all operations utilising the same surgical technique and prosthesis. Mean blood loss from intra-articular drains was not significantly different, being 141ml in the tranexamic acid group and 163ml in the control group. Circumferential leg measurements at levels above, through and below the knees were not significantly different between groups on day two post-operatively compared to pre-operatively. Intra-articular tranexamic acid instillation did not lead to a significant reduction in blood loss in these patients

Total hip arthroplasty (THA) is associated with high intraoperative and postoperative blood loss. Antifibrinolytic drugs have been used to minimize the potential risks of bleeding and blood transfusion. Studies on the effect of tranexamic acid on decreasing blood loss in THA have revealed interesting results, but most have focused on cemented THA. Yet its benefits in THA, especially in cementless THA, have not been proved. We conducted a prospective double-blind randomized controlled study on 64 patients who were candidates for cementless THA under epidural anesthesia between 2006 and 2008. Patients were randomly assigned into study and control groups. Patients in both groups were well matched regarding preoperative characteristics. Five minutes preoperatively 32 patients of the study and control groups received 15 mg/kg tranexamic acid or normal saline intravenously respectively. Our findings showed a significantly smaller decrease in 6- and 24-hour postoperative hemoglobin levels, less intraoperative and postoperative bleeding, and less need for allogenic blood transfusion in the tranexamic acid group. Our results also revealed a higher mean of 6- and 24-hour hematocrit level and shorter hospital stay in the tranexamic acid group compared to the control group, which were not statistically meaningful. In our study no thromboembolic event was seen; except 1 patient in the control group. Our study showed that administering tranexamic acid before the start of cementless THA under epidural anesthesia can reduce intraoperative and postoperative bleeding as well as need for blood transfusion

Purpose. The hip fracture has been increasing as the aging population continues to grow. Hip fracture patients are more susceptible to blood loss and venous thromboembolism (VTE). The objective of this study was to assess the efficacy and safety of tranexamic acid (TXA) in fracture patients undergoing fast-track hemiarthroplasty. Methods. 609 hip fracture patients undergoing hemiarthropalsty from January 2013 to September 2016 were prospectively selected. 289 patients received 15 mg/kg TXA prior to surgery, and the remaining 320 patients received no TXA. All the patients received a fast-track program including nutrition management, blood management, pain management, VTE prophylaxis and early mobilization and early intake. The primary outcome was transfusion requirement, other parameters such as blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay were also compared. Multivariate logistic regression analysis and meta-analysis were also performed to identify the risk factors of transfusion and confirm the results of current study. Results. Transfusion of at least 1U of erythrocyte blood cell occurred in 25 patients (8.65%) in treatment group and in 77 (24.06%, OR=0.299, p<0.001) in control group. The mean level of Hb on POD 1 (111.70±18.40 g/L) and POD 3 (108.16±17.25 g/L) in TXA group were higher than control group (107.29±18.70 g/L, p= 0.008; 104.22±15.16 g/L, p= 0.005 respectively). More patients get off bed to ambulate within 24 hours after surgery in TXA group (37.02% Vs 26.25%, p= 0.004). And the length of hospital stay was shorter (11.82±4.39 Vs 15.96±7.30, p= 0.003). No statistical significance were detected regarding VTE and other adverse events. Logistic regression analysis showed that the relative odds reduction after adjustment for these covariates was 67% (OR= 0.327, 95%CIs= 0.197 to 0.544) in favor of tranexamic acid. Other risk factors included preoperative hemoglobin level, operation time, VTE prophylaxis. Pooling the data showed that tranexamic acid led to a significant reduction in transfusion (OR= 0.33, 95%CIs= 0.25 to 0.43) without sacrificing safety (OR= 0.70, 95%CIs= 0.25 to 1.97). Conclusion. Tranexamic acid was effective and safe to reduce blood loss and transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty

Introduction & Aims. Intravenous administration of tranexamic acid (TXA) has been shown to be effective in reducing blood loss and transfusion requirements in total knee arthroplasty (TKA). However, concern exists that I.V. TXA may heighten the risk of venous thrombo-embolism. The intra-articular administration of TXA is an attractive and simple option to deliver this agent locally with minimal systemic effects on inducing hypercoagubale states. In this study, we analysed the effect of varying dosages of intra-articular tranexamic acid on blood loss in TKA. Methods. 176 patients who underwent a unilateral TKA for osteoarthritis were retrospectively analysed. Patients were excluded if they underwent a revision knee arthroplasty, concurrent removal of hardware, extensive synovectomy, or lateral patellar retinacular release. All patients underwent a primary cemented posterior stabilised TKA by 2 surgeons using a medial parapatellar approach. Tourniquet was only inflated for initial exposure and intra-articular drains were not used. Patients were separated into three groups; a control group (n=56) who did not receive TXA, and 2 treatment groups who received intra-articular TXA with doses of 1500 mg (n=60) or 3000 mg (n=60). Once the wound was closed, tranexamic acid was injected intra-articularly via an epidural pain catheter. Haemoglobin (Hb) levels were taken pre-operatively and on post-operative days 1 and 2. The primary outcome measure was mean difference in Hb drop between the three groups. Results. There was a statistically significant difference in post-operative Hb drops amongst the three groups. Those who received TXA had a greater reduction in the blood loss compared to the control group. In the control group, the mean haemoglobin pre-operatively was 140.13 g/L with an average drop of 34.30 g/L by post-operative day 2. Patients who received 1500 mg of TXA had a mean haemoglobin of 138.95 g/L pre-operatively with an average drop of 28.67 g/L by post operative day 2. Those who received 3000 mg had a pre-operative haemoglobin of 138.02 g/L with an average drop of 22.73 g/L. There were no differences in post-operative complications or local reactions. All inter-group differences in Hb drop on day 2 were statistically significant (p < 0.001, t tests and ANOVA). Conclusions. There appears to be a dose-dependent effect of intra-articular tranexamic acid on blood loss in TKA, with more efficacy with higher dosages. Intra-articular administration of TXA is an effective and simple way to decrease post-operative blood loss in TKA

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

To compare the efficacy of intra-articular and intravenous modes of administration of tranexamic acid in primary Total Knee Arthroplasty in terms of blood loss and fall in haemoglobin level. This randomized controlled trial was conducted from 12th May 2017 to 11th May 2017. Seventy eight patients were included in the study. Patients were randomly divided into group A and B. Group A patients undergoing unilateral primary total knee replacement (TKR) were given intravenous tranexamic acid (TXA) while group B were infiltrated with intra-articular TXA. Volume of drain output, fall in haemoglobin (Hb) level and need for blood transfusion were measured immediately after surgery and at 12 and 24 hours post operatively in both groups. The study included 35 (44.87%) male and 43 (55.13%) female patients. Mean age of patients was 61±6.59 years. The mean drain output calculated immediately after surgery in group A was 45.38±20.75 mL compared with 47.95±23.86 mL in group B (p=0.73). 24 hours post operatively, mean drain output was 263.21±38.50 mL in intravenous group versus 243.59±70.73 mL in intra-articular group (p=0.46). Regarding fall in Hb level, both groups showed no significant difference (p>0.05). 12.82% (n=5) patients in group A compared to 10.26% (n=4) patients required blood transfusion post operatively (p=0.72). Intra-articular and intravenous TXA are equally effective in patients undergoing primary total knee arthroplasty in reducing post operative blood loss. For any reader queries, please contact . drjunaidrmc@gmail.com

Tranexamic acid is a potent antifibrinolytic which has shown efficacy in reducing blood loss in total knee arthroplasty when administered intravenously. We performed a randomised controlled trial of oral tranexamic acid in total knee arthroplasty in order to assess the blood sparing effect of this preparation. We investigated the effects of oral tranexamic acid on blood loss in 50 patients (25 treatment arm and 25 placebo) undergoing unilateral total knee replacement in a two year period starting January 2007. The treatment arm received 1500 mg of encapsulated oral tranexamic acid TDS pre-operatively, with the third dose occurring within two hours of surgery, and a fourth dose six hours post surgery. The control arm received an identically encapsulated non-active formulation at the same dosing intervals. Baseline pre-operative haemoglobin and heamatocrit measures were collected. Outcome measures were post-operative haemoglobin and haematocrit taken 12 to 24 hours post operatively and total blood loss in wound drains at 24 hours. Results showed a non-clinically significant trend towards decreased blood loss and transfusion rates in the treatment arm when compared to placebo. No significant adverse events occurred in relation to the use of oral Tranexamic acid in this study. The perioperative use of oral tranexamic acid in conjuntion with elective total knee arthroplasty appears safe; however, its efficacy as a blood sparing medication is less than that which has been recorded with intravenous dosing. The study supports further consideration of the availability of intravenous tranexamic acid for decreasing blood loss in orthopaedic arthroplasty

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

Aim. To investigate the effect of Tranexamic acid on blood loss associated with Total Knee Replacement Surgery. Methods. A prospective double blind randomised controlled trial was conducted on 48 patients undergoing unilateral primary cemented total knee replacement. The mean age of the patients was 68 years. Recruitment was based on specific inclusion and exclusion criteria. Patients were randomised to receive either 10 mg/kg of tranexamic acid or a similar volume of normal saline at the time of cementing the prosthesis before deflation of the tourniquet. Both the patient and the surgeon were blinded to the type of injection. The post-operative blood loss was calculated in each case. Results. A statistically significant decrease in blood loss was noted at four (p=0.002) and eight hours (p=0.043) after knee replacement in the group receiving tranexamic acid. However there was no significant difference in total blood loss (p=0.09) at 24 hours between the two groups. Conclusion. Intra-operative administration of Tranexamic acid reduces blood loss after knee replacement surgery. The maximum reduction occurred in the first four hours after surgery, an effect likely to be related to the half life and minimum effective concentration of Tranexamic acid in the plasma. This study suggests that additional doses of tranexamic acid in the post-operative period may help to further reduce blood loss. However further study is needed to assess the safety and efficacy of prolonging this treatment

Introduction. Tranexamic acid (TXA) has been shown to decrease hemoglobin loss and reduce the need for transfusions in primary hip and knee arthroplasty. Recently, authors have proven similar results in revision total knee arthroplasty (TKA). No previous paper has focused on the safety and efficacy of TXA for revision TKA for periprosthetic joint infection (PJI). The purpose of our study was to evaluate the safety and efficacy of topical TXA in revision TKA for PJI. Methods. We performed a retrospective review of all patients who underwent two-stage revision total knee arthroplasty for infection at our institution between September 25, 2007 and July 12, 2013. We evaluated hemoglobin loss, need for transfusion, one-year reinfection rate, length of stay (LOS), complications and one-year mortality with and without the use of TXA in all patients who underwent Stage-1 removal of hardware with antibiotic spacer placement and/or revision (Stage-2) for PJI of the knee. All data sets were analyzed using a two-sample t-test. Results. During the study period, 45 patients underwent 49 Stage-1 procedures (20 knees with TXA, 29 without) and 44 patients underwent 47 Stage-2 revisions (28 with TXA, 19 without). Tranexamic acid use significantly decreased the hemoglobin loss in the Stage 1 group (19.8% vs 30.05%, p=0.0004) and the Stage-2 group (24.5% vs 32.01%, p=0.01). Furthermore, in both groups, the use of TXA was associated with a significant reduction in transfusion rates (Stage-1 25% vs 51.7%, p=0.04; Stage-2 25% vs 52.6%, p=0.05). There was a non-statistical decreased LOS of over a day in both groups (Stage-1 5.15 vs 6.72 days, p=0.055; Stage-2 5.21 vs 6.84 days, p=0.09). Finally, in both groups, there was no statistical difference in one-year re-infection rate (p=0.98) or one-year mortality (0 vs 0). There was a single upper extremity DVT around a PICC line, occurring in a patient who underwent a Stage 1 procedure augmented with topical TXA. There were no PEs. Conclusion. Topical tranexamic acid is both safe and effective for use in both stages of revision TKA for PJI. Despite the small number of patients, we show a significant reduction in the hemoglobin loss and transfusion requirement in both stages of TKA revision for PJI. Although it did not reach significance with our number of patients, we feel an average LOS over a day shorter in each group is a strong potential for cost savings. Previous studies have shown TXA to aggravate staphylococcal infection in mice, however, we show that topical TXA does not seem to have a negative effect on the treatment of PJI in our patients and does not increase the one-year re-infection or mortality rate