Intra-, periarticular TXA equally effective in reducing blood loss in TKA

Intra-articular (IA) and periarticular (PA) tranexamic acid (TXA) are both effective in lowering blood loss, easing postoperative pain, and improving functional outcomes in patients who underwent total knee arthroplasty (TKA), as shown in a Singapore study.

“[W]hile our study has shown no difference in outcomes between PA and IA TXA administration in TKA patients, local infiltration of analgesia and TXA proves to be a simple yet promising modality in ensuring reduced postoperative blood loss and maximizing pain relief and functional outcomes,” said the investigators, led by Dr Harish Sivasubramanian, Orthopaedic Surgery, Ng Teng Fong Hospital, Singapore.

Of the 63 patients who underwent TKA (54 percent female), 42 were assigned to the IA TXA delivery group and 21 to the PA TXA delivery group. All of them received 1 g of TXA, as well as pericapsular infiltration consisting of adrenaline 0.5 mL, morphine 0.4 mL, vancomycin 1 g, ketorolac 1 mL, and ropivacaine 15 mL.

Sivasubramanian and colleagues then measured the outcomes for blood loss and surrogate markers for immediate functional recovery.

The mean drop in postoperative haemoglobin levels was 2.0 g/dL in the PA group and 1.6 g/dL in the IA group, which did not reach statistical significance (p=0.10). Moreover, the mean haematocrit drop was 6.1 percent in the PA group and 5.3 percent in the IA group; this did not reach statistical significance as well (p=0.58). [Singapore Med J 2024;65:16-22]

Notably, the two groups showed similar outcomes, particularly in postoperative day (POD) 1 and discharge day flexion angles, POD 1 and POD 2 visual analogue scale scores, gait distance on discharge, and length of hospitalization.

“Although more studies are needed in future to establish the safety and efficacy of this method, early results from this pilot study are promising and this dual modality, local infiltration technique can be considered an option by the arthroplasty surgeon,” the investigators said.

Antifibrinolytic agent

TXA is an antifibrinolytic agent that has displayed its efficacy in reducing postoperative blood loss in various surgical and medical procedures, according to the investigators. “Even though there is literature evaluating intravenous (IV) and IA TXA, there is a paucity of studies on PA TXA, and the best route of administration remains a matter of contention.”

In the study by Maniar and colleagues, IA TXA reduced blood loss compared to no intervention. Likewise, Sarzaeem and colleagues found that IV TXA resulted in less blood loss relative to topical IA irrigation. [Clin Orthop Relat Res 2012;470:2605-2612; J Arthroplasty 2014;29:1521-1524]

On the other hand, a double-blinded randomized controlled trial by Chen and colleagues demonstrated similar effects of IV and IA TXA on transfusion indices and perioperative blood loss, with no differences in postoperative limb swelling as a complication. [Knee 2016;23:152-156]

“Furthermore, in an editorial evaluating the current evidence, Chen [and colleagues] concluded that even though there is no consensus in the literature with regard to the ideal route of administration, IA TXA can be recommended for patients in whom IV TXA is contraindicated, since the efficacy of IA TXA in reducing perioperative blood transfusion incidence is not inferior to that of IV TXA, and it does not have additional safety concerns,” the investigators said. [Ann Transl Med 2015;3:33]