Reducing post-operative bleeding after knee arthroplasty : intra-articular vs intravenous tranexamic acid

Abstract

Overview of the Topic: Total knee replacement (TKR) is indicated for severe osteoarthritic knees, but it is associated with significant blood loss with patients requiring blood transfusions. Still, transfusions carry their own risks, hence, interests in blood-conserving strategies have flourished. The use of anti-fibrinolytic agents, like tranexamic acid (TXA), blocks the activation of plasminogen to plasmin, thereby reducing the perioperative blood loss. The use of intravenous TXA in TKR is a routine practice. Several meta-analyses confirm its effectiveness in reducing blood loss and incidence of transfusion, without increasing the risk of thromboembolic events. Giving TXA intra-articularly, during TKR has only recently started to gain popularity. Yet, the ideal route of administering TXA still remains a controversial topic for ongoing debate. Research Question and its PCIO Elements This literature review intends to evaluate which is the ideal route in reducing post-op blood loss. The research question formulated through the PICO framework is as follows: “In patients undergoing total knee arthroplasty (P), does the use of tranexamic acid intraarticularly (I) versus intravenously (C) reduce post-operative bleeding (O) more effectively?” Inclusion Criteria: Studies in English published between 2007-2017; in the last 10 years, and published in peerreviewed journals were included. Human adult patients were included. Systematic reviews, meta-analyses, randomised controlled trials, cohort studies and case control studies were included. Exclusion Criteria: Studies not published in English, prior to 2007, not in peer-reviewed journals and including adults younger than 16 years of age, were excluded. Studies classified as opinion reports and case series were excluded. Outcomes of the Search: From 5 database searching, it resulted in seven articles well-suited to the project’s title: five randomised controlled trials and two meta-analyses. Methods of Appraisal: Tools used to critically appraise the literature were the Hierarchy of Evidence Model (Melnyk & Fineout-Overholt,2011), the JADAD scale for an RCT and the Critical Appraisal Skills Programme (CASP) Tools for Randomised Controlled Trials and Systematic Reviews. Main Results: Results suggests that the efficacy of intra-articular TXA in reducing post-operative blood loss is not inferior to intravenous TXA. Conclusion, Implications and Recommendations: Findings revealed that both routes of administration were comparable in their abilities to reduce total blood loss post-operatively. Obtained results call for extensive additional research and further studies in the field of intra-operative use of TXA intra-articularly to effectively improve patient outcomes post-operatively. Other recommendations also could include conducting studies using larger amount of participants to have more significant results.