The Change Of Blood Loss And Coagulation After Primary Unilateral Total Knee Arthroplasty

Improvements in health care have led to an increase in the number of aged people and huge of people suffering degenerative osteoarthritis of the knee.Total knee arthroplasty(TKA)can release pain,increase movement range of knee,and improve patients' life quality.However,TKA can cause estimated 1500 ml of blood loss on average because of massive tissuse exposion and bone cut.Anemia from blood loss may seriously impact patients with low hematopoietic ability.Swollen of the knee made it difficult to conduct the rehabilitation postoperatively,which is against to recovery.Reduce of blood loss,therefore,has positive contribution to clinical recovery and decrease the need for allogenic blood transfusion.Many methods have been reported to reduce blood loss including cryotherapy,intraoperative tourniquet use,specific drainage protocols,bipolar sealers,intra-articular injections of tranexamic acid(TXA),autologous platelet gels,and minimal incision method.TXA was the synthesis of the lysine and it can inhibit the activity of our fibrinolytic system.Recent studies reported that injection ot TXA into knee cavity can decrease the postoperative blood loss and relieve the swollen of knee.However,the application of TXA and drainage tube or not was still a question to answer.The use of fibrin sealant(FS)could be a promising approach to reduce bleeding and consequently lead to lower transfusion rates.Fibrin sealants have been increasingly used as adjunctive surgical and hemostatic agents for over 20 years.Fibrin sealants achieve their local hemostatic effects by reproducing the last step of the coagulation cascade,thereby facilitating formation of a stable fibrin clot and subsequent hemostasis.Special leg position can also reduce the blood loss as reported which is a cheap and easy way to applied in clinical practice.However,various angles were tested in different studies without consensus.We developed this study to assess the effects of intra-articular injection of TXA or FS on peri-operative blood loss undergoing primary unilateral TKA without drainage.We also determine the effect of postoperative hip elevation by 60° along with knee flexion by 60° on blood loss and related parameters following TKA.180 patients participated this study and equally allocated into six different groups,with comparable gender radio,age,body mass index,knee side and range of motion between six groups.Part 1 The reduction of blood loss in intra-articular application with tranexamic acid or fibrin sealant in unilateral total knee arthr-oplasty under different leg position.Objective: It is a randomized controlled trial to assess the effects of primary unilateral total knee arthroplasty(TKA)on perioperative blood loss with the purpose to find best procedures to lower blood loss.Methods: Patients with varus knee osteoarthritis,who were performed primary TKA without deep vein thrombosis tested by vein ultrasound,were randomized into extension or flexion leg position group.Patients in the extension group were set special leg position in which the operational legs were set at total extention,zero degree for both hip and knee.Patients in the flexion group were set at 60 degrees for both hip and knee.They were then randomized into three groups receiving 500 mg of tranexamic acid in 10 m L of normal saline solution,10 m L of fibrin sealant,or equivalent volume of normal saline solution without any drugs applied immediately after closure of the knee joint.10 m L of TXA,FS and saline solution was injected into the knee or sprayed on the internal aspects of the operative field before skin closure.Same procedures for antithrombosis were started immediately after operation,including phisical methods and low molecular weight heparin.Functional exersices were performed on each patient.They were followed up at 3,6 and 12 morths after discharge after hospital.The basic patients' information was recorded including sex,age,side and BMI.Weight and body length were used to estimate patients' total blood volume.Hemoglobin and haematocrit were tested the day before and after operation.Haematocrit was used to calculate total blood loss.Results: Preoperative hemoglobin was 136.0±10.6 g/L,134.3±11.2 g/L,137.5±7.9 g/L for the TXA group,FS group and control group with extention leg position.Preoperative hematocrit was 43.6±3.3%,41.7±4.4 % and 43.0± 3.6 % for the TXA group,FS group and control group with extention leg position.After 24 hours after operation,hemoglobin was 100.7±9.1 g/L,94.6±11.0 g/L and 86.6±7.1 g/L for the TXA group,FS group and control group with extention leg position.Postoperative hematocrit was 30.4±3.7 %,29.1±2.9 % and 25.6±2.4 % for the TXA group,FS group and control group with extention leg position.The total blood loss is 745.9±132.7ml,866.4± 202.1 ml and 985±162.0ml while hidden blood loss was 426.8±86.3ml,487.3±98.6 ml and 573.8±77.6 ml based on the preoperative hematocrit and that tested at the 24 hours postoperatively.One patient from the TXA group received 2 units of homologous blood transfusion.Four patients from the FS group received 10 units of homologous blood transfusion,while 9 patients from the TXA group received 22 units of homologous blood transfusion.Preoperative hemoglobin was 139.4±9.5 g/L,136.9±11.8 g/L and 137.4± 10.0 g/L for the TXA group,FS group and control group with flexion leg position.Preoperative hematocrit was42.3±3.6 %,41.4±4.0 % and 43.3±3.8 % for the TXA group,FS group and control group with flexion leg position.After 24 hours after operation,hemoglobin was 111.4±9.8 g/L,100.1±10.3 g/L and 90.2±8.5 g/L for the TXA group,FS group and control group with flexion leg position.Postoperative hematocrit was 35.2±2.6 %,32.3±2.4 % and 28.1±2.0 % for the TXA group,FS group and control group with extention leg position.The total blood loss is 667.7±120.9 ml,755.2±157.9 ml and 872.5±133.7 ml while hidden blood loss was 426.8±86.3 ml,487.3±98.6 ml and 573.8±77.6 ml based on the preoperative hematocrit and that tested at the 24 hours postoperatively.No patient from the TXA group received homologous blood transfusion.2 patients from the FS group received 4 units of homologous blood transfusion,while 5 patients from the TXA group received12 units of homologous blood transfusion.The difference of pre-or postoperative hemoglobin in TXA group with extention group was 3.9 g/L less than FS group with same leg position.The difference of pre-or postoperative hemoglobin in TXA group with flexion group was 6.9 g/L less than FS group,and 11.6 g/L less than that of control group with same leg position.When the hemoglobin was evaluated in TXA,FS or control group with different leg position,the difference of pre-or postoperative hemoglobin in TXA group with flexion leg position was 7.1 g/L less than extention group with significant statistical difference.The difference of pre-or postoperative hemoglobin in FS group with flexion leg position was 4.1 g/L less than extention group without significant statistical difference.The difference of pre-or postoperative hemoglobin in control group with flexion leg position was 1.8 g/L less than extention group without significant statistical difference.Either the total blood loss of hidden blood loss was different between six groups.The total blood loss of TXA group with extension was 239.5 ml less than that of control group,while hidden blood loss was 147.1 ml less than that of the control group.The total blood loss of TXA group with extension was 119 ml less than that of FS group,while hidden blood loss was 86.5ml less than that of the FS group.Based on these data,we knew that both TXA and FS can decrease blood loss,of which the TXA performed better than FS.When we evaluated blood loss bewteen TXA groups,FS groups and control groups with different leg positions,less blood loss(78.2 ml,111.2 ml and 112.9 ml)was noticed in flexion groups separately.Conclusion:1 Much blood was loset during the TKA;2 TXA,FS and flexion after operation can decrease blood loss;3 TXA with flexion leg position was the best method to control postoperative blood loss.Part 2 The effects of intra-articular application with tranexamic acid or fibrin sealant on coagulation and deep vein throbosis after uni-lateral total knee arthroplastyObjective: It is a randomized controlled trial to assess the effects of primary unilateral total knee arthroplasty(TKA)on perioperative coagulation with the purpose to find best procedures to lower deep vein throbosis.Methods: Patients with varus knee osteoarthritis,who were performed primary TKA without deep vein thrombosis tested by vein ultrasound,were randomized into different groups according to the same method descript in the part one.The basic patients' information was recorded including sex,age,side and BMI.D-Dimer was tested the day before operation,the day after operation and 7th day after operation,which were used to evaluate function of coaculatoin.Vein altrasound was tested at 7th day after operation to find deep vein thrombosis.Results: Preoperative D-dimer was 143.7±39.2 ng/m L,141.7±39.7 ng/ m L and 141.7±22.6 ng/m L for the TXA group,FS group and control group with extention leg position.Postoperative D-dimer after 24 hours increased to 1293.6±355.4 ng/m L,1101.9±417.4 ng/m L and 1104.3±354.0 ng/m L for the TXA group,FS group and control group with extention leg position.After 7 days after operation,D-dimer decreaesd to 517.9±164.5 ng/m L,548.0±241.4 ng/m L and 515.1±237.8 ng/m L for the TXA group,FS group and control group with extention leg position.Tested by vein ultrasound 9 patients in the extention group suffered DVT,most of which happened in less leg.According to DVT or not,the D-dimer of DVT group was 856.9±198 ng/m L,while it was 498.6±240 ng/m L in the no-DVT group,without no significant statistical difference.Preoperative D-dimer was 154.8±36.9 ng/m L,135.8±32.8 ng/m L and 150.9±44.6 ng/m L for the TXA group,FS group and control group with flxtion leg position.Postoperative D-dimer after 24 hours increased to 1228.6 ±258.0 ng/m L,1091.7±298.6 ng/m L and 1158.4±298.2 ng/m L for the TXA group,FS group and control group with flexion leg position.After 7 days after operation,D-dimer decreaesd to 555.9±196.3 ng/m L,620.9±200.0ng/m L and 565.6±195.4 ng/m L for the TXA group,FS group and control group with flexion leg position.Tested by vein ultrasound 11 patients in the extention group suffered DVT,most of which happened in less leg.According to DVT or not,the D-dimer of DVT group was 839.8±210 ng/m L,while it was 490.4±246 ng/m L in the no-DVT group,without no significant statistical difference.Conclusion:1 The D-dimer was elevated the first day after TKA and it decreased to some extent at 7th day;2 The DVT happened in 10% of all the patients at 7th day postoperatively,without significant relationship with D-dimer.Part 3 Effects of leg position with TXA or FS in knee on functional recovery following total knee arthroplastyObjective: It is a randomized controlled trial to assess the effects of primary unilateral total knee arthroplasty on post-operative function recovery with different anti-blood drugs and leg position.Methods: Patients with varus knee osteoarthritis,who were performed primary TKA without deep vein thrombosis tested by vein ultrasound,were randomized into different groups according to the same method descript in the part one.Functional exersices were performed on each patient.They were followed up at 3,6 and 12 morths after discharge after hospital.The basic patients' information was recorded including sex,age,side and BMI.The diameter of site at 10 cm above superlobe of patalla was measured to estimate swollen of knee after operation.The range of motion,VAS,KSS were measuered to evaluate function recovery.Results: The range of knee motion was 95.6±20.0°,92.3±20.0° and 92.8±22.1°for the TXA group,FS group and control group with extension leg position.It was increased to 116.2±7.4°,118.2±7.0° and 117.6±7.4°at 3 morths follow-up,117.8±6.6°,119.6±6.4° and 119.5±6.9°at 6 morths followup,and 118.0±6.7°,119.9±6.4° vs 120.9±6.0°at 12 morths follow-up.The preoperative VAS was 7.1±1.0,6.9±1.0 and 6.9±0.7 for the TXA,FS and group with extension leg position.It was decreased to 3.3±1.3,1.7±1.0 and 1.2±0.8°at 3,6,12 morths follow-up.It was decreased to 3.5±1.0,2.1±1.0 and 1.7±0.5 at 3,6,12 morths follow-up in the FS group.It was decreased to 2.9±1.0?2.0±1.0 and 1.6±0.5 at 3,6,12 morths follow-up in the control group.The preoperative KSS was 53.9±6.1,53.7±6.2 and 53.3±5.4 for the TXA,FS and group with extension leg position.It was decreased to 75.0±7.4,83.2±5.8 and 90.1±3.4 at 3,6,12 morths follow-up.It was decreased to 77.8±10.4,83.7±8.1 and 88.9±6.5 at 3,6,12 morths follow-up in the FS group.It was decreased to 78.0±8.2,82.9±6.4 and 88.4±5.1 at 3,6,12 morths follow-up in the control group.The range of knee motion was 96.7±15.7°,92.2±16.7° and 97.8±18.8°for the TXA group,FS group and control group with flexion leg position.It was increased to 118.2±6.8°,114.5±7.1° and 115.0±9.0 at 3 morths follow-up,120.6±5.9°,118.4±4.4° and 119.5±6.2 °at 6 morths follow-up,and 20.0±6.3°,120.5±4.4° and 119.9±6.4°.The preoperative VAS was 6.9±1.0?6.5±1.0 and 6.5±1.3 for the TXA,FS and group with extension leg position.It was decreased to 3.3±1.3,2.0±1.1 and 1.1±0.8 at 3,6,12 morths follow-up in the TXA group.It was decreased to 3.3±1.3,2.0±1.1 and 1.1±0.8 at 3,6,12 morths follow-up in the FS group.It was decreased to 2.7±0.9,2.2±0.7 and 1.4±0.7 at 3,6,12 morths follow-up in the control group.The preoperative KSS was 54.8±4.9,53.4±5.4 and 54.3±5.4 for the TXA,FS and group with extension leg position.It was increased to 75.2±8.3,81.1±6.7 and 87.0±4.7 at 3,6,12 morths follow-up.It was increased to 75.4±5.8,82.0±6.9 and 86.1±6.0 at 3,6,12 morths follow-up in the FS group.It was increased to 75.9±6,81.2±6.1 and 87±6.0 at 3,6,12 morths follow-up in the control group.Conclusion: TKA can improve the knee function with lower VAS postoperatively.The leg position didn't have significant effect on the function.