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      INTRAARTICULAR EPSILON AMINOCAPROIC ACID VERSUS TRANEXAMIC ACID IN TOTAL KNEE ARTHROPLASTY Translated title: ACIDO ÉPSILON AMINOCAPROICO INTRA-ARTICULAR VERSUS ACIDO TRANEXÂMICO NA PRÓTESE TOTAL DO JOELHO

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          ABSTRACT

          Objective:

          To examine and compare the clinical efficacy of intraarticular epsilon aminocaproic acid (EACA) and tranexamic acid (TXA) in total knee arthroplasty (TKA).

          Methods:

          This study was a prospective, single-center, double-blinded randomized controlled trial, including sixty patients with osteoarthritis of the knee divided into two groups of 30 patients. In the TXA group, 1 g of TXA (0.05 g/ml) was applied intraarticularly, and in the EACA group, 4 g of EACA (0.2 g/ml) was applied intraarticularly. Serum hemoglobin (Hgb) and hematocrit (Htb) were measured during the preoperatively and 24 and 48 hours postoperatively. The range of motion and pain were evaluated by clinical examination. To evaluate knee function before and 2 months after surgery, the Western Ontario and McMaster Universities Index (WOMAC) questionnaire was used.

          Results:

          In total, 56 (93.3%) patients were evaluated up to the second postoperative month. No significant difference between the groups (p > 0.05) was found in the decrease in Hgb or Htb at 24 or 48 hours. Regarding assessment of the pain, WOMAC score and gain in knee flexion, no significant advantages up to 60 days after surgery (p > 0.05) were found.

          Conclusions:

          The decrease in Hgb and Htb during the first 48 hours postoperatively and the risk of transfusion were similar with the intraarticular use of 1 g of TXA and 4 g of EACA in TKA. The possible benefits regarding knee pain, gain in flexion and function were also similar for the two drugs. Level of Evidence II, Randomized, Double-Blinded, Single-Centre, Prospective Clinical Trial.

          RESUMO

          Objetivo:

          Avaliar e comparar a eficácia clinica do uso intra-articular do ácido épsilon aminocaproico (AEAC) versus o ácido tranexâmico (ATX) na prótese total do joelho.

          Métodos:

          Estudo clínico prospectivo, centro-único, duplo-cego e randomizado. Sessenta pacientes com osteoartrose de joelho foram incluídos. Os participantes foram divididos em dois grupos de 30 pacientes. No grupo ATX, foi aplicado 1 g de ATX (0.05 g/ml) intra-articular e, no grupo AEAC, foram aplicados 4 g de AEAC (0.2 g/ml) intra-articular. Valores séricos da hemoglobina (Hb) e hemtatócrito (Ht) foram dosados no pré-operatório e com 24 e 48 horas após a cirurgia. A amplitude de movimento e a dor também foram avaliadas no exame clínico. O índice WOMAC foi utilizado para avaliar a função do joelho antes e após dois meses da cirurgia.

          Resultados:

          Foram avaliados 56 (93.3%) pacientes até o segundo mês pós-operatório. Depois da cirurgia, não houve diferenças entre os grupos (p > 0.05) na queda do valor de Hb e Ht com 24 ou 48 horas. Com relação à avaliação da dor, WOMAC e ganho de flexão do joelho, não houve vantagem significativa para nenhum dos grupos até os 60 dias depois da cirurgia(p > 0.05).

          Conclusão:

          A queda do valor da Hb e do Ht durante as primeiras 48 horas pós-operatórias e o risco de transfusão foram similares com o uso intra-articular de 1 g de ATX e 4 g de AEAC na artroplastia total do joelho. Os possíveis benefícios com relação ao controle da dor, ganho de flexão e função foram similares entre as duas drogas. Nível de Evidência II, Ensaio-Clínico Prospectivo, Randomizado, Duplo Cego, Centro-Único.

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          Most cited references14

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          Tranexamic acid in total knee replacement: a systematic review and meta-analysis.

          We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the effect of tranexamic acid (TXA) upon blood loss and transfusion in primary total knee replacement. The review used the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. A total of 19 trials were eligible: 18 used intravenous administration, one also evaluated oral dosing and one trial evaluated topical use. TXA led to a significant reduction in the proportion of patients requiring blood transfusion (risk ratio (RR) 2.56, 95% confidence interval (CI) 2.1 to 3.1, p 4 g) TXA showed a plausible consistent reduction in blood transfusion requirements (RR 5.33; 95% CI 2.44 to 11.65, p < 0.001; I(2) = 0%), a finding that should be confirmed by a further well-designed trial. The current evidence from trials does not support an increased risk of deep-vein thrombosis (13 trials, 801 patients) or pulmonary embolism (18 trials, 971 patients) due to TXA administration.
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            Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial.

            Risks and costs of allogeneic blood transfusions mandate strategies to reduce blood loss in surgery. The objective of this study was to assess the efficacy of antifibrinolytic treatment in reducing perioperative blood loss during total knee replacement. A double-blind, randomized and placebo-controlled clinical trial was carried out on 127 patients undergoing total knee replacement. Patients in the study group received tranexamic acid 10 mg kg(-1) i.v. just before the tourniquet was deflated and 3 h later, or epsilon-aminocaproic acid 100 mg kg(-1) before tourniquet deflation followed by continuous perfusion (1 g h(-1)) during 3 h. External perioperative blood loss was measured and total blood loss was calculated. The number of patients transfused and number of packed red cell (PRC) units transfused was recorded and possible postoperative thromboembolic complications were investigated. Total blood loss [mean (sd)] was 1099 ml (535) in the group that received antifibrinolytic agents and 1784 ml (660) in the control group (P<0.001). Five patients (7.5%) in the study group and 23 (38.3%) in the control group (P<0.001) received blood transfusions; the first group received a mean of 0.10 PRC unit per patient and the second, 0.58 (P<0.001). Mean reduction in haemoglobin levels (g dl(-1)) between preoperative and fifth day postoperative readings was 2.5 (0.9) in the study group and 3.4 (1.2) in the control group (P<0.001). Clinical assessment did not reveal any thromboembolic complications. Antifibrinolytic agents produce a significant decrease in blood loss in patients undergoing total knee replacement, reflected in a reduction in the number of blood transfusions required.
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              Efficacy of intra-articular tranexamic acid in blood loss reduction following primary unilateral total knee arthroplasty.

              The surgical stress of total knee arthroplasty (TKA) procedure and the application of intra-operative pneumatic thigh tourniquet increases local fibrinolytic activity, which contributes significantly to post-operative blood loss. Tranexamic acid, an antifibrinolytic drug, is commonly used to control post-operative blood loss. The recommended mode of administration of tranexamic acid is either oral or intravenous. However, the mechanism of action of the tranexamic acid points towards the possible effectiveness it may have following local/intra-articular application. This prospective, double-blinded, randomized preliminary study evaluated the efficacy of intra-articular tranexamic acid in reducing TKA-associated post-operative blood loss.
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                Author and article information

                Journal
                Acta Ortop Bras
                Acta Ortop Bras
                aob
                Acta Ortopedica Brasileira
                ATHA EDITORA
                1413-7852
                1809-4406
                Nov-Dec 2021
                Nov-Dec 2021
                : 29
                : 6
                : 312-315
                Affiliations
                [1 ]Uniort.e Orthopedic Hospital, Londrina, PR, Brazil.
                [2 ]Londrina Evangelic Hospital, Londrina, PR, Brazil.
                [3 ]Universidade Estadual Paulista Júlio de Mesquita Filho, Botucatu, SP, Brazil.
                Author notes
                Correspondence: João Paulo Fernandes Guerreiro. Av. Higienópolis, 2.600, Londrina, PR, Brazil, 86050170. drjoaopauloguerreiro@ 123456gmail.com

                All authors declare no potential conflict of interest related to this article.

                AUTHORS’ CONTRIBUTIONS: : Each author contributed individually and significantly to the development of this article. JPFG: drafted and reviewed the article, performed statistical analysis and contributed to the intellectual concept of the study and the entire research project; JRMB: drafted the article, sought volunteers and analyzed the data; BPR: drafted the article, sought volunteers and analyzed the data; MVD: reviewed the article and contributed to the intellectual concept of the study; AOQ: reviewed the article and contributed to the intellectual concept of the study; DCC: reviewed the article and contributed to the intellectual concept of the study.

                Author information
                http://orcid.org/0000-0002-2026-9176
                http://orcid.org/0000-0001-6608-7864
                http://orcid.org/0000-0003-2990-7901
                http://orcid.org/0000-0001-7547-7557
                http://orcid.org/0000-0003-2808-7892
                http://orcid.org/0000-0002-3400-2309
                Article
                10.1590/1413-785220212906242008
                8601385
                34849096
                943ab3a7-bd25-4a8c-9ab0-fd67336a7627

                This is an open-access article distributed under the terms of the Creative Commons Attribution License

                History
                : 10 August 2020
                : 20 October 2020
                Page count
                Figures: 2, Tables: 6, Equations: 0, References: 14, Pages: 4
                Categories
                Original Article
                Knee

                total knee arthroplasty,bleeding,pain,tranexamic acid,epsilon aminocaproic acid,artroplastia total do joelho,sangramento,dor,ácido tranexâmico,ácido épsilon aminocapróico

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