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CURRENT CONCEPTS
Blood Control in Total Knee Arthroplasty
David Sadigursky, MD, MSc
Orthopedic and Traumatologic Clinic – COT
Hospital Manoel
Victorino – Attending Surgeon; Faculty of the Orthopedic and Traumatology Fellowship Program
Salvado, BA, BRAZIL
The total knee arthroplasty (TKA), as any surgical procedure, is liable to a series of post-operative complications, such as, particularly in this procedure, excessive blood loss associated, prolonged hospitalization, with an increase in hospital expenses and a decrease in patient satisfaction.
Aiming to minimize intra- and postoperative bleeding as well as their complications, some alternatives are constantly studied. Among them, we find in the literature the use of hypotensive anesthesia, tourniquet use, intraopera- tive blood salvage, re-infusion drains, radiofrequency bipolar, or manipulation of the coagulation cascade, adrenaline, fibrin glue sprays, FloSeal®, auto-transfusion, as the most common procedures. The use of the plasminogen-activator inhibitor tranexamic acid (TA) has arisen interest as an inexpensive agent to be held in surgical procedures worldwide. Thus, the analysis of the clinical efficacy of the use of TA in reducing blood loss in TKA is of paramount importance as the current literature lacks clarity regarding the best dosage and the most effective timing of administration.
Different dosages and method of TA application can be found in the literature and can be shown in Table 1, according to the RCTs analysed.
Author and publishing year
Aguilera X et al., 2013
Pachauri et al., 2013
Kim TK et al., 2013
Roy SP et al., 2012
Wong J et al., 2010
Kankar PN et al., 2009
Camaras et al., 2006
Type of Intervention
Use of fibrin glue, fibrinogen and troponin, and intravenous tranexamic acid
02 doses of tranexamic acid, injection, first dose one hour preoperatively and six hours postoperatively
01 dose before incision and a dose (10mg.kg-1) of tranexamic acid before tourniquet deflation
Use of tranexamic acid, 5ml, administered intra-articularly after the procedure
Use of tranexamic acid 1.5 to 3.0 g applied for five minutes in the joint at the end of surgery
Use of tranexamic acid 10mg.kg-1 just before inflation of the tourniquet followed by 1mg.kg-1 until the end of the procedure
Use of tranexamic acid 10mg.kg-1 just before inflation of the tourniquet followed by 1mg.kg-1 until the end of the procedure
01
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At our institution, we performed a systematic review selecting papers analysing the effectiveness of TA in TKA over the last 10 years. In the first search, 59 articles were found of which seven randomized control trials (RCT) met the inclusion criteria and were selected with a total sample of 948 patients. After the analysis of and the comparison between the studies included in this work we can conclude that the use of TA in TKA, whether unilateral or bilateral, reduces blood loss in peri- and postoperative procedures significantly when compared to other antifibrinolytic agent. With the reduction of total blood loss, decrease in hemoglobin and haematocrit rate, and the reduction in the need for blood transfusions, the use of tranexamic acid has being demonstrated to be safe with no increase in side effects, such as venous thromboembolism. The use of TA as a hemostasis mechanism can reduce costs and shorten hospital stays, also avoiding the use of autologous blood transfusion.