This randomized controlled trial compared intravenous and topical tranexamic acid alone to tranexamic acid with tourniquet use for primary total knee arthroplasty. The study found that intravenous and topical tranexamic acid alone were superior to using a tourniquet, with less blood loss, less pain, and higher patient satisfaction. While no differences in deep vein thrombosis or pulmonary embolism were observed, the group receiving only tranexamic acid had fewer wound complications compared to the group that also received a tourniquet. The study demonstrates that tourniquets may not be necessary when intravenous and topical tranexamic acid are used for primary total knee replacement.

1. Journal club
Intravenous and Topical
Tranexamic Acid Alone Are
Superior to Tourniquet Use for
Primary Total Knee Arthroplasty
A Prospective, Randomized
Controlled Trial
ZeYu Huang, MD, PhD*, XiaoWei Xie, MD*, LingLi Li, MNS*, Qiang Huang, MD,
Jun Ma, MD, Bin Shen, MD, PhD, Virginia Byers Kraus, MD, PhD, and FuXing Pei,
MD
-Dr Shalabh Kumar
senior resident
AIIMS (R)

2. • Level 1 Randomized controlled trial
• Performed at the Department of Orthopedic
Surgery, West China Hospital, West China
Medical School, Sichuan University, ChengDu,
Sichuan Province, People’s Republic of China
• June 2015 to december 2015

3. Hypothesis
• They hypothesized that tourniquet use is not
necessary when intravenous and topical TXA is
utilized in primary total knee arthroplasty

6. What is tranexamic acid ?
• Tranexamic acid is an antifibrinolytic agent
- It competitively inhibits activation of plasminogen
thereby reducing conversion of plasminogen to
plasmin (fibrinolysin), an enzyme that degrades fibrin
clots, fibrinogen, and other plasma proteins,
including the procoagulant factors V and VIII.
• It also directly inhibits plasmin activity, but higher
doses are required than are needed to reduce
plasmin formation.

7. What is tourniquet ?
• Constricting or compressing device used to control
venous and arterial circulation to an extremity for a
period of time.
• Pressureis appliedcircumferentiallyupon the skin underlying
tissues of thelimb
• Pressureis transferred to the
vesselwalls, occludingthem

8. • Pressure of 135 to 255 mm Hg for upper limbs
• 175 to 305 mm Hg for lower extrimities
• Wide cuffs are more effective at lower
pressure
• 10 cm width in arm & 15 cm in thigh
• Curved tourniquets for conical extrimities

9. • Perioperative blood loss - one of the major
complications
• Can exceed 1,000 mL, or approximately 20% of the
body’s total blood volume.
• As a routine practice, surgeons apply a tourniquet
during total knee arthroplasty to reduce blood loss and
improve surgical field visualization.
• Disadvantages -
– reduced early knee flexion
– increased perioperative pain
– increased postoperative limb swelling
– frequent wound complications.

10. • Asymptomatic pulmonary embolism within
one minute of tourniquet release
• Tournquet paralysis
• Compartment syndrome
• Rhabdomylosis
• Post tourniquet syndrome

11. Materials and Methods
• Randomized control study
• INCLUSIONS
-All patients 18 years of age or older who were
scheduled for a primary total knee
arthroplasty for end-stage osteoarthritis were
eligible for inclusion

12. • EXCLUSIONS
- revision procedures
- bilateral procedures
- previous knee surgery
- flexion deformity of 30 degree or more
- varus-valgus deformity of 30 degree or more
- anemia (hemoglobin [Hb] level of <12 g/dL for
women and <13 g/dL for men)
- contraindications for the use of TXA (h/o
blood clot events within 6 months)
- Coagulation disorder
- ASA grade IV

14. Patients randomized into 3 groups;
Group A
tourniquet + i.v tranexamic acid (20mg/kg)
5-10 min before skin incision
1 gm of topical in 50 ml NS
10mg/kg, 3,6,12,24 hrs later
Group B
iv tranexamic acid only (same doses)

15. Group C
tourniquet only
In Groups A and C, the tourniquet was inflated
to 100 mm Hg above systolic pressure before the
incision and deflated after closure of the incision

16. Surgical procedure

17. • under general anesthesia, by 1 surgical team
composed of 2 senior orthopaedic surgeons.
• The operations were done in the standard way, using a
midline skin incision, a standard medial parapatellar
approach, and a measured resection technique.
• Vaccum wound drainage
• No blood salvage system was used; electrocautery and
routine hemostasis were performed during the surgery.
• Surgical time, intraoperative blood loss, and drainage
volume were recorded

18. • Postoperatively- anesthesia recovery unit for 1
hour, and then to the inpatient unit
• Cold pack for 12 hours
• Intraoperative periarticular injection of
ropivacaine
• Postoperative oral diclofenac sodium (Voltaren;
50 mg twice daily) were administered for pain on
the day of the surgery and 3 times daily
thereafter until hospital discharge

19. • Physical therapist for all
• Began walking with partial weight-bearing and
wearing a knee brace to protect the surgical
site.
• Mechanical and chemical DVT prophylaxis

20. • Doppler ultrasound was used to evaluate for
DVT at the time of discharge and at 1, 3, and
6-month follow-up evaluations, or at any time
that DVT was clinically suspected.
• Criteria for transfusion included
-symptomatic anemia
- in a patient with an Hb level of 7 to 10 g/dL
- Hb level of <7 g/dL regardless of
accompanying symptoms

22. Outcome measurements
• Data on patient demographics, medical
history, concomitant medications, length of
hospital stay, and any complications were
collected along with a complete blood-cell
count, hepatic function, blood creatinine level,
blood urea nitrogen (BUN) level, prothrombin
time (PT), activated partial thromboplastin
time (aPTT), and platelet count during the
inpatient hospitalization and at 1week and
1,3,and 6 months postoperatively.

23. • The complete blood-cell count and levels of
inflammatory markers (C-reactive protein
[CRP] and interleukin-6 [IL-6]) were tested on
postoperative days 1, 2, 3, and 5.

24. Statical analysis
• Quantitative data
– Applied ANOVA and Tukey post hoc test
• Qualitative data
– Pearson chi square test
– Fischer exact test

26. Results
• Blood loss

27. Results
- Pain

28. • Inflammatory markers

29. • Patient Satisfaction
At the time of discharge, patients in Group B
had significantly higher satisfaction ratings
than both Groups A and C (100% at least
somewhat satisfied compared with 96% [p =
0.035] and 72% [p < 0.001], respectively)
(Table III).
• At the 6-month follow-up evaluation, there
were no significant differences in satisfaction
among the 3 groups

30. Complications
• DVT or PE
Neither of them occurred in any patient.
Postoperatively, routine Doppler ultrasound
showed that 13 patients (6 from Group A, 4
from Group B, and 3 from Group C) developed
intramuscular venous thrombosis. The
differences among the groups were not
significant (p = 0.672).

31. Infection
One patient from Group A and 3 patients
from Group C developed superficial infection,
which was controlled with dressing changes
and oral antibiotics.

32. Wound secretion
occurred in 15 patients (6 from Group A and
9 from Group C). No wound secretion was
observed in Group B during the entire follow-
up period, and this represented a significant
difference compared with Group
A(p=0.027)andGroupC(p=0.003).
Blistering
was reported in 3 patients from Group C and
no patients in Group A or B.

33. LIMITATIONS
• short follow-up
• prosthetic fixation and survival outcomes
were outside the scope of this study
• although this study showed a low frequency
of DVT, PE, and other complications, a larger
sample size would be needed to adequately
evaluate for significant group differences in
these adverse events

34. TAKE HOME MASSAGE
• Tranexamic acid decreases blood loss and post
operative morbidity
• Proper use of tourniquet in respect of time
and pressure