Total Knee Arthroplasty: Superiority of Intra-Articular Tranexamic Acid Over Intravenous and Cell Salvage as Blood Sparing Strategy – A Retrospective Study

Abstract

Purpose

Total knee arthroplasty is associated with considerable perioperative hemorrhage. The decrease in hemoglobin concentration and the need for allogenic blood transfusion are related to increased morbidity and mortality. Strategies for minimizing perioperative bleeding are used, such as tranexamic acid and cell salvage. The study aimed to compare intravenous, intra-articular tranexamic acid and cell salvage protocols regarding perioperative hemoglobin variation. Secondary outcomes included blood loss; allogenic transfusions; complications and in-hospital stay.

Patients and Methods

Patients submitted to unilateral total knee arthroplasty between January and December 2018 were retrospectively evaluated. After excluding 62 patients, 204 were subdivided into 3 groups according to the protocol used. Statistical analysis was performed with SPSS version 26.0. One-way ANOVA and Kruskal–Wallis tests were used. Considered a p-value of <0.05 for statistical significance.

Results

Variation of hemoglobin in the intra-articular tranexamic acid group was significantly lower than that of intravenous (p < 0.001) and cell salvage (p = 0.001) groups. Blood loss, variation of hematocrit, need for blood transfusion and in-hospital stay were also statistically significantly lower in the intra-articular tranexamic acid group. The only related complications were in the intravenous tranexamic acid group. No thromboembolic complications were identified which further solidifies the safety of tranexamic acid administration.

Conclusion

This data shows superiority of the intra-articular administration of tranexamic acid over the other techniques in total knee arthroplasty. We propose this protocol as an efficient, low-risk blood-sparing strategy.

Graphical Abstract

Keywords:

• arthroplasty
• knee
• acid tranexamic
• salvage
• transfusion

Abbreviations

CBC, complete blood count; Hb, hemoglobin; Htc, hematocrit; PLT, platelets; TKA, total knee arthroplasty; TXA, tranexamic acid; TXA-art, intra-articular tranexamic acid; TXA-iv, intravenous tranexamic acid; vHb, hemoglobin variation; vHtc, hematocrit variation; vPLT, platelets variation.

Ethics Approval and Informed Consent

The Comissão de Ética (Institutional Review Board) of the Centro Hospitalar do Baixo Vouga (Aveiro), approved this research study. The review board has waived the need for informed consent as it is a retrospective study, all patients had signed consent for the surgical and anesthetic procedure and blood transfusions and no extraordinary interventions were performed. The data was accessed only by the authors and confidentiality of the patients was maintained at all times, in compliance with the Declaration of Helsinki.

Acknowledgments

No acknowledgements to be stated in terms of contributions, technical help of financial support.

Author Contributions

All authors had an important role in designing the study, presenting it to the ethical committee, gathering information, treating the data, writing, and reviewing the manuscript. All revisions and alterations were agreed upon by all authors. All authors decided together to which journal the study should be sent and are accountable for the contents of the article.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.