0
Commentary and Perspective   |    
Commentary on an article by Jean Wong, MD, FRCPC, et al.: “Topical Application of Tranexamic Acid Reduces Postoperative Blood Loss in Total Knee Arthroplasty: A Randomized, Controlled Trial”
David F. Dalury, MD
View Disclosures and Other Information
The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (DePuy).

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Nov 03;92(15):e25 1-2. doi: 10.2106/JBJS.J.01137
The main article is available here
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case
Blood loss following total knee replacement is a major concern of both patients and surgeons. The authors of this study are to be commended for designing a rigorous study that is clinically relevant to this topic. The objective of the study was to evaluate the efficacy of topical tranexamic acid in decreasing blood loss following total knee replacement.
This prospective, double-blinded, controlled study was performed to evaluate the relative efficacy of two different dosages of tranexamic acid, delivered topically at the end of total knee replacement, in decreasing blood loss postoperatively. The authors controlled as many variables as possible, with all patients being enrolled in a similar blood-conservation program and deep-vein thrombosis (DVT) prophylaxis protocol. Patients were randomized to one of three groups and received either 1.5 or 3 g of tranexamic acid or a placebo. All patients were evaluated with regard to blood loss, postoperative hemoglobin level, and function, and all had screening for DVT with use of ultrasound. The most important finding of the study was that patients who were given tranexamic acid had significantly lower blood loss in comparison with the control group. The authors were unable to identify any advantage of the larger dose and found no difference between the patients and the controls in terms of any of the outcomes. A novel finding of this study was that the authors systematically screened patients who were treated with the drug and found no increase in the occurrence of DVT.
Tranexamic acid is one of several antifibrinolytics that have been successfully used to decrease blood loss in patients undergoing surgery. The drug, which blocks the lysine binding site of plasminogen, has been found to be both safe and effective for decreasing blood loss in patients undergoing cardiac, oral, and spine surgery. There have been several recent studies of this drug following total knee replacement and total hip replacement1-4. Each of those studies demonstrated that use of the drug was safe and led to a decrease in the need for transfusions.
While not a major focus of the current paper, the issue of costs associated with decreasing blood loss following total knee replacement should be considered. The cost of this drug, particularly when administered topically, is substantially lower than that associated with the use of fibrin sealants5 and autologous blood donations for the treatment of postoperative anemia.
Several concerns regarding these drugs have limited their more widespread use. Issues such as a potentially increased risk of thrombosis in this already high-risk group and a potential problem related to the intravenous administration of tranexamic acid have been raised. The current study addressed both of these questions. By delivering the medication topically, at the site most needed, the investigators obviated the risks of intravenous administration. Their finding of a 20% to 25% decrease in postoperative bleeding is comparable with the findings of other studies in which the drug was administered intravenously. Their routine use of postoperative Doppler studies, which showed no increased findings of thromboembolic events following the use of this drug, is an important finding.
The authors correctly point out that further study with larger numbers of patients is needed to demonstrate the safety and efficacy of this drug. However, this well-done study adds to the growing literature supporting the use of tranexamic acid as an effective treatment for decreasing blood loss following total knee replacement.
Ralley  FE;  Berta  D;  Binns  V;  Howard  J;  Naudie  DD. One intraoperative dose of tranexamic acid for patients having primary hip or knee arthroplasty. Clin Orthop.  2010;468:1905-11.[PubMed][CrossRef]
 
MacGillivray  RG;  Tarabichi  SB;  Hawari  MF;  Raoof  NT. Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty. J Arthroplasty.   2010 Feb 18 [Epub ahead of print].
 
Tanaka  N;  Sakahashi  H;  Sato  E;  Hirose  K;  Ishima  T;  Ishii  S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br.  2001;83:702-5.[PubMed]
 
Camarasa  MA;  Ollé  G;  Serra-Prat  M;  Martín  A;  Sánchez  M;  Ricós  P;  Pérez  A;  Opisso  L. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anesth.  2006;96:576-82.
 
Molloy  DO;  Archbold  HA;  Ogonda  L;  McConway  J;  Wilson  RK;  Beverland  DE. Comparison of topical fibrin spray and tranexamic acid on blood loss after total knee replacement. J Bone Joint Surg Br.  2007;89:306-9.[PubMed]
 

Submit a comment

References

Ralley  FE;  Berta  D;  Binns  V;  Howard  J;  Naudie  DD. One intraoperative dose of tranexamic acid for patients having primary hip or knee arthroplasty. Clin Orthop.  2010;468:1905-11.[PubMed][CrossRef]
 
MacGillivray  RG;  Tarabichi  SB;  Hawari  MF;  Raoof  NT. Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty. J Arthroplasty.   2010 Feb 18 [Epub ahead of print].
 
Tanaka  N;  Sakahashi  H;  Sato  E;  Hirose  K;  Ishima  T;  Ishii  S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br.  2001;83:702-5.[PubMed]
 
Camarasa  MA;  Ollé  G;  Serra-Prat  M;  Martín  A;  Sánchez  M;  Ricós  P;  Pérez  A;  Opisso  L. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anesth.  2006;96:576-82.
 
Molloy  DO;  Archbold  HA;  Ogonda  L;  McConway  J;  Wilson  RK;  Beverland  DE. Comparison of topical fibrin spray and tranexamic acid on blood loss after total knee replacement. J Bone Joint Surg Br.  2007;89:306-9.[PubMed]
 
Accreditation Statement
These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
CME Activities Associated with This Article
Submit a Comment
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe





Related Content
The Journal of Bone & Joint Surgery
JBJS Case Connector
Topic Collections
Related Audio and Videos
PubMed Articles
Clinical Trials
Readers of This Also Read...
JBJS Jobs
04/16/2014
Georgia - Choice Care Occupational Medicine & Orthopaedics
04/16/2014
Ohio - OhioHealth Research and Innovation Institute (OHRI)
02/05/2014
Oregon - The Center - Orthopedic and Neurosurgical Care and Research