Original Research

Blood Loss Reduction with Tranexamic Acid and a Bipolar Sealer in Direct Anterior Total Hip Arthroplasty

Publish date: May 15, 2018

References

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Tranexamic acid (TXA), a synthetic analog of the amino acid lysine, is one antifibrinolytic that has recently been adopted in total joint arthroplasty. TXA competitively inhibits the lysine binding site of plasminogen, inhibiting fibrinolysis and leading to clot stabilization.^18-20 Because of its safety and low cost, TXA has been readily accepted. The bipolar sealer enhances surgical hemostasis by sealing vessels at the surgical site through radiofrequency ablation. In contrast to standard electrocautery, a bipolar sealer uses saline to maintain tissue temperatures at <100°C, minimizing damage to surrounding tissues.²¹ Many applications of a bipolar sealer have been reported in the fields of surgical oncology,²¹ pulmonary surgery,²¹ liver resection,²²THA^23,24 and TKA,^25,26 and spine surgery.²⁷ We recently published our reduction in transfusion rates during direct anterior (DA) THA with use of a bipolar sealer.²⁸

Although many studies have analyzed the use of TXA and a bipolar sealer with the posterior and lateral approaches to hip arthroplasty, there is a paucity of research analyzing its use in the DA approach. This study retrospectively reviews the effectiveness of TXA alone and in conjunction with a bipolar sealer in reducing allogeneic blood transfusions in DA THA.

METHODS

This is a retrospective, comparative study evaluating the efficacy of TXA with and without a bipolar sealer in unilateral DA THA. The study included 173 patients who underwent standard DA THA performed by 2 surgeons in the period April 2013 to April 2014. Patient demographic information is summarized in Table 1.

Table 1. Demographic Data

	All (N = 173)	TXA Only (n = 63)	TXA + Bipolar Sealer (n = 49)	Control (n = 61)	P-value (TXA vs Control)	P-value (TXA + Sealer vs Control)	P-value (TXA + Sealer vs TXA)
Age (y)^a	64.8 ± 10.5 (28.4-87.6)	66.9 ± 9.9 (47.2-87.6)	62.1 ± 11.0 (28.4-86.3)	64.7 ± 10.4 (38.3-85.8)	.31	.24	.03
Gender^b					.99	0.95	.94
Male	82 (47.4%)	30 (47.6%)	23 (46.9%)	29 (47.5%)
Female	91 (52.6%)	33 (52.4%)	26 (53.1%)	32 (52.5%)
BMI (kg/m^2)a	27.9 ± 4.4 (17.5-40.6)	27.8 ± 3.3 (21.6-35.9)	29.1 ± 5.3 (17.8-40.6)	27.0 ± 4.5 (17.5-39.8)	.16	.03	.13
Preoperative hemoglobin level^a	13.6 ± 1.3 (10.5-17.2)	13.9 ± 1.2 (11.5-17.1)	13.5 ± 1.4 (10.5-16.6)	13.5 ± 1.2 (10.5-17.2)	.10	.98	.10

^aResult values are expressed as mean ± standard deviation (range). ^bResult values are expressed as number of cases (percentage of column header population).

Abbreviations: BMI, body mass index; TXA, tranexamic acid.

Three cohorts were created based on intraoperative blood loss management practices at the surgeon’s discretion. The first group included 63 patients who underwent DA THA with TXA but not a bipolar sealer. The second group included 49 patients who underwent DA THA with TXA and a bipolar sealer. The third (control) group included 61 patients who underwent DA THA without TXA or a bipolar sealer. Data for the control group were collected prospectively as a part of a randomized trial, which demonstrated a reduction in transfusion requirements and blood loss with the use of a bipolar sealer in DA THA.²⁸ All patients received a surgical hemovac suction drain, which was removed at 24 hours after surgery. All patients received 40 mg of enoxaparin daily for 2 weeks for venous thromboembolism prophylaxis starting the day after surgery.

All patients in the first 2 groups received 2 g of TXA administered intravenously in 2 doses: the first dose was given preoperatively, and the second dose was given immediately postoperatively in the recovery room. The bipolar sealer was utilized as needed perioperatively according to the manufacturer’s instructions to address specific bleeding targets. The common sites and steps of a DA THA, in which bleeding typically occurs, are:

The medial femoral circumflex artery during the approach to the capsule;
The anterior hip capsule vessels prior to capsulotomy;
The deep branch of the medial femoral circumflex artery and the nutrient vessels to the lesser trochanter encountered while exposing the medial neck and releasing the medial capsule;
The posterior-superior retinacular arteries encountered after femoral neck osteotomy and removal of the femoral head along the posterior capsule; and
The branch of the obturator artery encountered during exposure of the acetabular fovea.^29-31

At the time of this study, the transfusion criteria included hemoglobin <8 g/dL in the presence of clinical symptoms.

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