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.

Total joint arthroplasty is commonly associated with post-operative anemia. Blood conservation programs have been developed to optimise patients prior to surgery. Epoetin Alfa (Eprex) or intravenous (IV) iron transfusions are two modalities that can be used pre-operatively to optimise hemoglobin and ferritin levels. There are, however, potential complications and increased costs associated with their use. Oral iron is a less costly option for those undergoing surgery but requires more time to take effect. There are no studies to date that examine the effects of an early screening program utilising oral iron supplementation prior to total joint arthroplasty. The purpose of this study is to evaluate the effect of implementing early pre-operative oral iron supplementation on patients prior total joint arthroplasty.

A retrospective review of patients undergoing total joint arthroplasty was performed using our institution clinical informatics database. We identified all patients seen in pre-admission clinic (PAC) between Jan 1, 2009 and March 31, 2010 representing our control group. We then identified all patients seen in PAC between October 1, 2012 and December 31, 2013. Patients in this cohort received screening blood work when booked for surgery, and oral iron supplementation was given to patients with hemoglobin of less than 135g/L or ferritin less than 100ug/L, thus representing our treatment group. Patients undergoing revision, uni-compartment knee arthroplasty and bilateral arthroplasties were excluded from the study. Pearson Chi-Square tests were used to calculate significance between groups with main outcomes including pre-admission hemoglobin, and pre-operative requirements for Eprex or IV iron.

In our control group, we identified 354 patients (25.6%) with hemoglobin less than 130 g/L at time of pre-admission clinic. In our treatment group, this number dropped significantly to only 16.4% of patients (p<0.005).

Implementation of an early screening program using oral iron supplementation resulted in a decrease in the number of patients with hemoglobin lower than 130 g/L at the time of pre-admission clinic. There was also a significant decrease in the use of Eprex and IV iron pre-operatively in the patients in the early screening program. These results encourage the use of early oral iron supplementation for patients with hemoglobin less than 135 g/L or ferritin less than 100ug/L in order to optimise patients prior to total joint arthroplasty.

Purpose: Multiple studies have demonstrated the efficacy of Tranexamic Acid (TA) in reducing blood loss and red blood cell transfusion in patients undergoing primary total hip (THA) or knee (TKA) arthroplasty. However, the dosing schedules of either an initial bolus followed by a 6–12 hour infusion or multiple intravenous bolus doses are not ‘user-friendly’ for regular application. The purpose of this study was to assess the efficacy and acceptance of a single dose protocol for the use of TA in primary THA or TKA.

Method: We selected a single dosing schedule of 20mg/kg TA given either prior to skin incision for THA or approximately ten minutes prior to tourniquet release for TKA. The hospital pharmacy supplied the TA rounded off to the nearest 5kg/100mg in a 100ml mini-bag. In March 2008, we introduced the routine use of TA to all patients undergoing primary THA or TKA at our institution. Mini-bags were pre-ordered at the time of the preoperative clinic visit and delivered to the pre-surgical preparation area on day of surgery. One month after implementation of this protocol we compared blood loss, transfusion rates, and hemoglobin at discharge between the patients operated on from April 1 to June 30, 2007 (when this protocol was not in place) to those from April 1 to June 30, 2008. No other routine patient care practices were altered during this time period.

Results: We found a significant reduction in the decrease in hemoglobin from 2007 compared to 2008 for both THA and TKA (46g/L to 39g/L, and 45g/L to 36g/L, respectively), which led to both a reduction in transfusion rates (13.5% to 3.6%, and 13.1% to 2.0%, respectively) and higher hemoglobin levels at discharge. All patients received the TA as ordered.

Conclusion: Dosing and timing of TA is critical to maximize its antifibrinolytic effect. Our weight increment dose protocol led to minimal dose variability, facilitated pharmacy drug preparation, and minimized wastage. This simple ‘user-friendly’ protocol was found to reduce the decrease in hemoglobin and transfusion rates, demonstrating similar efficacy to other more complex dosing schedules. This protocol was well received and accepted by surgeons, anesthesiologists, pharmacy, and nursing staff.

The purpose of this study was to evaluate the impact of dalteparin use on transfusion rates and blood loss in patients undergoing primary total joint arthroplasty at our center.

We prospectively studied the transfusion patterns of 1642 patients who underwent primary total hip or knee arthroplasty between January 2004 and December 2005 by five arthroplasty surgeons. The influence of daltaperin use, release of tourniquet in total knee arthroplasty, and the turnover of house staff were analyzed using SPSS V14.0 statistical software.

We identified seven hundred and three total hip and nine hundred and thirty-nine knee arthroplasty patients. The mean haemoglobin drop was statistically significant between 2004 and 2005 (p< 0.001). This was seen in both hip (p=0.014) and knee (p< 0.001) patients. Subgroup analysis of total knee arthroplasty revealed a significant difference in haemoglobin drop between surgeons who released the tourniquet prior to closure compared to release at the end of the case (p=0.005). In addition, there were significant monthly differences that corresponded with the turnover of house staff (p=0.039). Overall, no statistically significant increase in allogeneic transfusion rates was observed between years, months, and individual surgeons.

The use of dalteparin was found to be associated with a significantly increased haemoglobin drop in primary total joint replacement when compared to warfarin. However, the use of dalteparin was not associated with an increase in allogeneic transfusions at our center. The results also suggest that there may be an advantage to releasing the tourniquet and achieving hemostasis prior to closure in knee arthroplasty. Finally, the results emphasise the importance of educating new house staff on methods to reduce intra-operative blood loss and transfusion rates.