Journal of Orthopaedic Surgery 2016;24(2):179-82

Topical tranexamic acid versus autotransfusion

after total knee arthroplasty
Yunus Guzel, Osman T Gurcan, Umut H Golge, Turan C Dulgeroglu, Hasan Metineren
Ordu University Medical School, Turkey

ABSTRACT
Purpose. To compare the use of topical tranexamic
acid (TXA) with postoperative autologous transfusion
(PAT) in terms of blood loss, need for allogeneic blood
transfusion, and cost-effectiveness.
Methods. Records of 25 men and 125 women (mean
age, 67 years) who underwent primary unilateral
total knee arthroplasty (TKA) and were randomised
to the PAT group (n=50), topical TXA group (n=50),
or routine drainage group (control) [n=50] were
reviewed. Pre- and post-operative haemoglobin level,
total postoperative drainage volume, and the need
for allogeneic blood transfusion were recorded.
Results. The 3 groups were comparable in terms of
age, gender, and preoperative haemoglobin level. The
total postoperative drainage volume was lower in the
TXA group than the PAT or routine drainage groups
(174.48 vs. 735 vs. 760 ml, p<0.001). The postoperative
haemoglobin level was lower in the routine drainage
group than the PAT or TXA groups on day 1 (11.67 vs.

12.33 vs. 12.40 g/dl, p<0.001) and day 3 (9.9 vs. 10.7
vs. 11.14 g/dl, p<0.001). The number of patients who
received allogeneic blood transfusion was higher
in the routine drainage group (12 and 4 patients
received 1 and 2 units of blood, respectively) than
the PAT group (4 patients received 1 unit of blood) or
the TXA group (none required transfusion) [p<0.001],
and the respective total transfusion cost was $1200,
$240, and $0. The total cost was lowest in the TXA
group followed by the routine drainage group and
PAT group ($200 vs. $1200 vs. $12 390). No patient
developed acute infection, deep venous thrombosis,
pulmonary embolism, myocardial infarction, or
stroke.
Conclusion. Compared with PAT, topical TXA
was more cost-effective and resulted in less total
postoperative drainage volume and less need for
allogeneic blood transfusion.
Key words: arthroplasty, replacement, knee; blood loss,
surgical; blood transfusion, autologous; hemostasis,
surgical; tranexamic acid

Address correspondence and reprint requests to: Yunus Guzel, Ordu University Medical School, Turkey. Email:
dryg@windowslive.com

Journal of Orthopaedic Surgery

180 Y Guzel et al.

INTRODUCTION
To reduce blood loss and the need for allogeneic blood
transfusion during total knee arthroplasty (TKA),
application of controlled hypotensive anaesthesia,
delayed drainage, tourniquet release before wound
closure, topical or systemic tranexamic acid (TXA),
and postoperative autologous transfusion (PAT)
has been advocated.115 TXA is an analogue of the
amino acid lysine. When administered systemically,
TXA competitively inhibits plasminogen activation
and plasmin binding to fibrin, thus inhibiting fibrin
degradation. When used topically, TXA acts directly
on microvasculature and clot stabilisation, thus
reducing local bleeding.47,14,15 PAT re-infuses blood
collected in the surgical drain into the patient and thus
reduces the need for allogeneic blood transfusion.813
This study compared the use of topical TXA with
PAT in terms of blood loss, need for allogeneic blood
transfusion, and cost-effectiveness.
MATERIALS AND METHODS
This study was approved by the ethics committee of
our hospital. Records of 176 patients who underwent
primary unilateral TKA between October 2013 and
November 2014 by a single team of surgeons with
standardised anaesthetic and surgical protocols
were reviewed. Of them, 26 patients with a history
of venous thromboembolism, preoperative use of
anticoagulants (acetylsalicylic acid, enoxaparin, or
any other oral or intravenous agent), obvious anaemia
or coagulopathy before surgery were excluded. The
remaining 25 men and 125 women (mean age, 67
years) were randomised to the PAT group (n=50),
topical TXA group (n=50), or routine drainage group
(control) [n=50].
Cemented TKA was performed through a
standard medial parapatellar approach with
tourniquet use under spinal or regional block or
general anaesthesia. A posterior cruciate ligamentpreserving prosthesis was used. The patellar surface
was not changed. An intramedullary guide was used
for femoral preparation, and an extramedullary guide
was used for tibial preparation. Thromboembolismdeterrent stockings and enoxaparin (40 mg before
surgery and continued daily for 10 days) were used
as venous thromboembolism prophylaxis.16
For the topical TXA group, a drain and injector
tip were placed within the joint before closing the
arthrotomy. The drain was clamped and 1.5 g TXA
(Transamine, FAKO, Istanbul, Turkey) diluted in
100 ml normal saline was injected intra-articularly

via the injector tip. The drain was released after one
hour.
For the PAT group, the CellTrans (SUMMIT,
Gloucestershire, UK) was used. A drain was inserted
into the knee joint at the end of TKA, and low suction
drainage was started 30 minutes later. More than 150
ml of blood had accumulated within 6 hours and was
re-infused into the patient. After that, the system was
used as a normal closed drain system.
For the controls, a low-suction drain was placed
in the knee joint and removed after 24 hours.
Blood transfusion was indicated when the
haemoglobin (Hb) level fell below 8 g/dl or the patient
was symptomatic of anaemia. The postoperative Hb
level was measured daily, and the lowest value was
used for analysis. Transfusion cost per 1 unit of red
blood cells was estimated to be $60 in 2014 at our
hospital; the cost of 1.5 g of TXA was approximately
$4 and the cost of PAT using the CellTrans system was
approximately $243 in 2014.1720
Doppler ultrasonography was used to detect
proximal or distal deep venous thrombosis.
Ventilation/perfusion scanning or spiral computed
tomography was used only when pulmonary
embolism was suspected clinically; this avoided
unnecessary exposure to radiation and additional
costs.
The normality of distribution of the continuous
variables was tested by the Kolmogorov-Smirnov test.
The ANOVA test was used for normally distributed
numerical variables (Hb level), whereas the KruskalWallis test was used for nonnormally distributed
numerical variables (drain volume). Sub-group
analyses were made using the Mann-Whitney U test.
Patients who did or did not receive allogeneic blood
transfusion were compared using the Chi-square
test. A value of p<0.05 was considered statistically
significant.
RESULTS
The 3 groups were comparable in terms of age,
gender, and preoperative haemoglobin level (Table).
The total postoperative drainage volume was lower
in the TXA group than the PAT or routine drainage
groups (174.48 vs. 735 vs. 760 ml, p<0.001). The
postoperative Hb level was lower in the routine
drainage group than the PAT or TXA groups on day
1 (11.67 vs. 12.33 vs. 12.40 g/dl, p<0.001) and day 3
(9.9 vs. 10.7 vs. 11.14 g/dl, p<0.001). The number of
patients who received allogeneic blood transfusion
was higher in the routine drainage group (12 and 4
patients received 1 and 2 units of blood, respectively)

Vol. 24 No. 2, August 2016

Topical tranexamic acid versus autotransfusion after TKA 181

Table
Patient characteristics and outcome*

Parameter

Topical tranexamic
acid group (n=50)

Age (years)
Male
Female
Haemoglobin level (g/dl)
Preop
Postop day 1
Postop day 3
Total drain output (ml)
Unit of allogeneic blood transfusion
Total transfusion cost (US$)
Total cost (US$)

Postoperative
autologous transfusion
group (n=50)

Routine drainage
group (n=50)

p Value

66.55.1
7 (14)
43 (86)

66.95.1
8 (16)
42 (84)

674.5
10 (20)
40 (80)

0.35
0.64
0.72

13.660.82
12.400.69
11.140.77
174.48128
0 (0)
0
200

13.80.65
12.330.67
10.70.85
735191.8
4 (8)
240
12 390

13.690.61
11.670.70
9.900.70
760145
20 (40)
1200
1200

0.527
<0.001
<0.001
<0.001
<0.001
-

* Data are presented as no. (%) or meanSD

than the PAT group (4 patients received 1 unit of

blood) or the TXA group (none required transfusion)
[40% vs. 8% vs. 0%, p<0.001], and the respective
total transfusion cost was $1200, $240, and $0. The
total cost was lowest in the TXA group followed by
the routine drainage group and PAT group ($200
vs. $1200 vs. $12390). No patient developed acute
infection, deep venous thrombosis, pulmonary
embolism, myocardial infarction, or stroke.
DISCUSSION
It is important to reduce blood loss during TKA in
elderly patients with limited cardiovascular function.
Tourniquet use is the most common method to
limit blood loss.21 Application of PAT and topical
or systemic TXA to achieve surgical haemostasis
without tourniquet use is increasingly popular.
Compared with routine drainage, PAT enabled
a higher postoperative Hb level and lower blood
loss, with the cost of PAT being $75 and the cost
of allogeneic blood transfusion (including crossmatching, delivery and refrigerated storage) being
$761.8 Another study reported the cost for one unit
of allogeneic blood transfusion as $787 and the cost
of TXA as $58.6 In a meta-analysis, the use of PAT
reduced the need for allogeneic blood transfusion
and decreased postoperative hospital costs.22 In our
study, TXA was cheaper, more accessible, and easier
to apply than PAT, although there was no significant

difference in postoperative Hb level between TXA

and PAT. Topical application of TXA is more or
equally effective compared with systemic use.5,23,24
The amount of systemic absorption of TXA following
topical application can be clinically disregarded.14
There is no evidence that topical or systemic
application of TXA is associated with an increased rate
of venous thromboembolism, myocardial infraction,
or stroke.48,2527 The dosage of topical TXA varies and
has been reported to be 3 g TXA/100 ml saline,5 1 g
TXA/10 ml saline,6 1.5 g TXA/50 ml saline,28 and 1.5
g and 3 g TXA/100 ml saline.14
This study had several limitations. It was
retrospective. Postoperative pain, wound healing,
and time to discharge were not evaluated. TKAs
were performed by 2 different surgeons, but the
anaesthetic and surgical protocols and prosthesis
were standardised.
CONCLUSION
Compared with PAT, topical TXA was more costeffective and resulted in less total postoperative
drainage volume and less need for allogeneic blood
transfusion.
DISCLOSURE
No conflicts of interest were declared by the authors.

182 Y Guzel et al.

Journal of Orthopaedic Surgery

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