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Abundant literature confirms that intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) reduces blood loss in total knee arthroplasty (TKA). Oral formulations of TXA exhibit profound cost-saving benefits. However, comparisons of the clinical efficacy among three different modalities of TXA administration have not been previously investigated in the setting of TKA with no closed suction drain and tourniquet. A total of 180 patients undergoing TKA were randomized to receive 2-g oral TXA 2 hours preoperatively, 20-mg/kg IV TXA 5 minutes prior to incision, or 2-g IA TXA. The primary outcome was 72-hour blood loss. Secondary outcomes were reductions in hemoglobin, the rate of transfusions, and adverse events. No significant differences were identified with regard to the mean 72-hour blood loss among the three groups (1003 mL in oral group, 1108 mL in IV group, and 1059 mL in IA group, respectively). Similarly, hemoglobin reduction was equivalent among the groups. Only one patient in IV group exhibited deep venous thrombosis. No difference was identified regarding transfusion rates. Oral TXA results in similar blood loss in TKA, with a profound cost-saving benefit, compared with the IA and IV formulations.

The reductions of perioperative blood loss and inflammatory response are important in total knee arthroplasty. Tranexamic acid reduced blood loss and the inflammatory response in several studies. However, the effect of epinephrine administration plus tranexamic acid has not been intensively investigated, to our knowledge. In this study, we evaluated whether the combined administration of low-dose epinephrine plus tranexamic acid reduced perioperative blood loss or inflammatory response further compared with tranexamic acid alone.This randomized placebo-controlled trial consisted of 179 consecutive patients who underwent primary total knee arthroplasty. Patients were randomized into 3 interventions: Group IV received intravenous low-dose epinephrine plus tranexamic acid, Group TP received topical diluted epinephrine plus tranexamic acid, and Group CT received tranexamic acid alone. The primary outcome was perioperative blood loss on postoperative day 1. Secondary outcomes included perioperative blood loss on postoperative day 3, coagulation and fibrinolysis parameters (measured by thromboelastography), inflammatory cytokine levels, transfusion values (rate and volume), thromboembolic complications, length of hospital stay, wound score, range of motion, and Hospital for Special Surgery (HSS) score.The mean calculated total blood loss (and standard deviation) in Group IV was 348.1 ± 158.2 mL on postoperative day 1 and 458.0 ± 183.4 mL on postoperative day 3, which were significantly reduced (p0.05) compared with Group TP at 420.5 ± 188.4 mL on postoperative day 1 and 531.1 ± 231.4 mL on postoperative day 3 and Group CT at 520.4 ± 228.4 mL on postoperative day 1 and 633.7 ± 237.3 mL on postoperative day 3. Intravenous low-dose epinephrine exhibited a net anti-inflammatory activity in total knee arthroplasty and did not induce an obvious hypercoagulable status. Transfusion values were significantly reduced (p0.05) in Group IV, but no significant differences were observed in the incidence of thromboembolic complications, wound score, range of motion, and HSS score among the 3 groups (p0.05).The combined administration of low-dose epinephrine and tranexamic acid demonstrated an increased effect in reducing perioperative blood loss and the inflammatory response compared with tranexamic acid alone, with no apparent increased incidence of thromboembolic and other complications.Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objective To evaluate whether closed suction drainage (CSD) is associated with early recovery of knee function in patients undergoing total knee arthroplasty (TKA). Methods Between January 2015 and September 2015, 80 consecutive patients were prospectively randomized into two groups: a CSD group (40 cases; average age, 66.9 ± 8.6 years; male, 8; female, 32) and a non-CSD group (40 cases; average age, 66.8 ± 10.1 years; male, 9; female, 31). Local inflammation outcomes (assessed by a visual analog scale [VAS], swelling and skin temperature), calculated total blood loss (CBL), hidden blood loss (HBL), blood transfusion requirements and hemoglobin concentrations were recorded. Hospital for Special Surgery (HSS) knee scores, range of motion (ROM), limb swelling, tension vesicles, ecchymosis, time to regaining straight leg raising and duration of hospital stay were documented. All surgeries were performed by the same surgeon and followed up for 3 months. Results The peri-wound skin temperature and knee VAS pain scores were lower in the non-CSD group. Patients in the non-CSD group had significantly better knee ROM (P = 0.028). The time to regaining active straight leg raising was significantly shorter in the non-CSD groupN than in the CSD group (P = 0.014). In addition, patients in the non-CSD group had a shorter length of hospital stay (P = 0.004) than those in the CSD group, indicating earlier recovery of knee function. HBL was significantly less in the CSD group than the non-CSD group (P = 0.006) on postoperative day (POD) 5. However, CBL did not differ significantly between the two groups on POD5. There were no significant differences between two groups in all other assessed variables. Conclusion In this randomized study, primary TKA without CSD was associated with faster recovery related to less local inflammation and better early knee function. Furthermore, use of a drain had no significant advantage with respect to other outcome measures and may have increased costs. Based on these data, CSD after primary TKA is not routinely indicated.

Objective To assess the difference between drainage and non-drainage after total hip arthroplasty (THA) in Chinese subjects by evaluating post-operative complications and joint function. Methods One hundred and sixty-eight patients undergoing THA were randomly allocated into drainage (83 patients) and non-drainage groups (85 patients). All surgeries were performed by one surgical team using the same pre-, intra-, and postoperative techniques. Measured items included: hemoglobin (Hb), superficial and deep wound infection, volume of blood transfusion, wound hematoma thickness, range of motion (ROM) of the hip, wound healing time, ecchymosis and tension vesicles around the wound. Results Early after THA, the Hb decreased significantly in the drainage group. There was no significant difference between non-drainage and drainage groups in need for or volume of blood transfusions (9.6% vs 8.2%, P = 0.100; 3.8 units vs 2.9 units, P = 0.089, respectively). In the non-drainage group, the incidence of superficial infection, ecchymosis and tension vesicles was significantly higher than in the drainage group (10.6% vs 2.4%, P = 0.031; 12.9% vs 3.6%, P = 0.026; 16.5% vs 4.8%, P = 0.013, respectively). In addition, the non-drainage group had a greater volume of hematomas (P = 0.000). Patients in the non-drainage group had smaller ROMs early after surgery but the final ROMs did not differ significantly between groups. No deep infection occurred in either group. Conclusion Non-drainage may reduce postoperative blood loss but has no benefits regarding blood transfusion or deep infection. It may cause more post-operative complications because of restriction of early postoperative exercise by pain and swelling. Therefore we suggest routine use of drainage after THA.

OBJECTIVE: To assess the difference between drainage and non‐drainage after total hip arthroplasty (THA) in Chinese subjects by evaluating post‐operative complications and joint function. METHODS: One hundred and sixty‐eight patients undergoing THA were randomly allocated into drainage (83 patients) and non‐drainage groups (85 patients). All surgeries were performed by one surgical team using the same pre‐, intra‐, and postoperative techniques. Measured items included: hemoglobin (Hb), superficial and deep wound infection, volume of blood transfusion, wound hematoma thickness, range of motion (ROM) of the hip, wound healing time, ecchymosis and tension vesicles around the wound. RESULTS: Early after THA, the Hb decreased significantly in the drainage group. There was no significant difference between non‐drainage and drainage groups in need for or volume of blood transfusions (9.6% vs 8.2%, P = 0.100; 3.8 units vs 2.9 units, P = 0.089, respectively). In the non‐drainage group, the incidence of superficial infection, ecchymosis and tension vesicles was significantly higher than in the drainage group (10.6% vs 2.4%, P = 0.031; 12.9% vs 3.6%, P = 0.026; 16.5% vs 4.8%, P = 0.013, respectively). In addition, the non‐drainage group had a greater volume of hematomas (P = 0.000). Patients in the non‐drainage group had smaller ROMs early after surgery but the final ROMs did not differ significantly between groups. No deep infection occurred in either group. CONCLUSION: Non‐drainage may reduce postoperative blood loss but has no benefits regarding blood transfusion or deep infection. It may cause more post‐operative complications because of restriction of early postoperative exercise by pain and swelling. Therefore we suggest routine use of drainage after THA.