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. 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).Aims
Patients and Methods
We hypothesised there was no clinical value in
using an autologous blood transfusion (ABT) drain in either primary total
hip (THR) or total knee replacement (TKR) in terms of limiting allogeneic
blood transfusions when a modern restrictive blood management regime
was followed. A total of 575 patients (65.2% men), with a mean age
of 68.9 years (36 to 94) were randomised in this three-arm study
to no drainage (group A), or to wound drainage with an ABT drain
for either six hours (group B) or 24 hours (group C). The primary
outcome was the number of patients receiving allogeneic blood transfusion.
Secondary outcomes were post-operative haemoglobin (Hb) levels,
length of hospital stay and adverse events. This study identified only 41 transfused patients, with no significant
difference in distribution between the three groups (p = 0.857).
The mean pre-operative haemoglobin (Hb) value in the transfused
group was 12.8 g/dL (9.8 to 15.5) Cite this article:
Post-operative complications after total hip
or knee replacement can delay recovery, prolong hospitalisation, increase
rates of re-admission and, in the most severe cases, lead to long-term
disability or even death. In this analysis of pooled data from four
large, randomised, phase III clinical trials that compared the oral,
direct Factor Xa inhibitor rivaroxaban with subcutaneous enoxaparin
for the prevention of venous thromboembolism after total hip or
knee replacement (n = 12 729), the incidence of complications, including
bleeding and adverse events related to surgery (such as wound infection,
wound dehiscence and haemarthrosis) are reported. Interventions
and procedures relating to surgery are also compared between the
groups. Bleeding events, including excessive wound haematoma and
surgical-site bleeding, occurred at similar rates in the rivaroxaban
and enoxaparin groups. Over the total study duration, adverse surgical
events occurred at a similar rate in the rivaroxaban group compared
with the enoxaparin group after total knee replacement (2.26% This analysis shows that the incidence of adverse surgical events
with rivaroxaban was similar to enoxaparin.
In order to compare the effect of oral apixaban
(a factor Xa inhibitor) with subcutaneous enoxaparin on major venous
thromboembolism and major and non-major clinically relevant bleeding
after total knee and hip replacement, we conducted a pooled analysis
of two previously reported double-blind randomised studies involving 8464
patients. One group received apixaban 2.5 mg twice daily (plus placebo
injection) starting 12 to 24 hours after operation, and the other
received enoxaparin subcutaneously once daily (and placebo tablets)
starting 12 hours (± 3) pre-operatively. Each regimen was continued
for 12 days ( Apixaban 2.5 mg twice daily is more effective than enoxaparin
40 mg once daily without increased bleeding.
We performed a meta-analysis of modern total
joint replacement (TJR) to determine the post-operative mortality and
the cause of death using different thromboprophylactic regimens
as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent
anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran,
fondaparinux or rivaroxaban); 3) Potent anticoagulation combined
(PAC) with regional anaesthesia and/or pneumatic compression devices
(PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia
and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional
anaesthesia, PCDs and aspirin in low-risk patients. Cause of death
was classified as autopsy proven, clinically certain or unknown.
Deaths were grouped into cardiopulmonary excluding pulmonary embolism
(PE), PE, bleeding-related, gastrointestinal, central nervous system,
and others (miscellaneous). Meta-analysis based on fixed effects
or random effects models was used for pooling incidence data. In all, 70 studies were included (99 441 patients; 373 deaths).
The mortality was lowest in the MM (0.2%) and WC (0.2%) groups.
The most frequent cause of death was cardiopulmonary (47.9%), followed
by PE (25.4%) and bleeding (8.9%). The proportion of deaths due
to PE was not significantly affected by the thromboprophylaxis regimen (PA, 35.5%;
PAC, 28%; MM, 23.2%; and NRC, 16.3%). Fatal bleeding was higher
in groups relying on the use of anticoagulation (W, 33.8%; PA, 9.4%;
PAC, 10.8%) but the differences were not statistically significant. Our study demonstrated that the routine use of PA does not reduce
the overall mortality or the proportion of deaths due to PE.
