Combination Intravenous and Intra-Articular Tranexamic Acid Compared with Intravenous Only Administration and No Therapy in Total Knee Arthroplasty: A Case Series Study

Introduction Excessive perioperative bleeding requiring transfusion remains a potential complication of Total Knee Arthroplasty (TKA). There is overwhelming evidence supporting the efficacy of intravenous Tranexamic acid to reduce bleeding and the need for transfusion in TKA. There is still some question regarding the efficacy of other methods of Tranexamic acid administration. This case series study evaluated the effects of the use of intravenous Tranexamic acid administered alone, or in combination with intra-articular tranexamic acid on transfusion rate and other clinical outcomes; and compared this to a group of patients who received neither treatment. Method We conducted a case review of 150 patients who had undergone TKA from 2012-2015. 50 patients underwent TKA with IV Tranexamic acid (Group A). A further 50 patients underwent TKA with IV Tranexamic acid in combination with intra-articular administration of 2grams of Tranexamic acid in 20ml saline (Group B). A final 50 patients underwent TKA without the use of Tranexamic acid (non-treatment group). Outcome measures were transfusion rate, change in haemoglobin and haematocrit, medical review events, patient mortality and changes in knee flexion and extension measurements at six weeks after surgery. Results There were no significant differences in red blood cell transfusion rates between the non-treatment group and the two treatment groups, however an absolute reduction in transfusion rate from 8% to 0% (p=0.134) was observed. The mean change of haemoglobin level in the non-treatment group was 29 while in treatment groups A and B, this was 23 and 19 respectively (p=0.0001). No significant difference was observed between treatment group A and B.  There was a significant difference in post-operative haemoglobin level, where mean haemoglobin concentrations in non-treatment, Group A and B were 110 vs 115 vs 123 respectively (P= 0.0001). Pairwise comparison showed that Group B was significantly different when compared to both non treatment (p=0.0001) and treatment group A (p=0.020).  There were no significant differences observed in other outcomes. Conclusion This study supports the existing literature and suggests that the use of IV Tranexamic acid alone or in combination with intra-articular dose in TKA may reduce the requirement for transfusion (Level IV evidence). Furthermore, this study suggests that the use of tranexamic acid as a combination of Intravenous and intra-articular administration has no effect on range of motion, or medical complications during hospital stay. Although it was not a statistically significant finding, our study suggested a trend towards a greater reduction in haemoglobin and haematocrit fall in the combination therapy group when compared to IV Tranexamic acid alone