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Regarding “Intra-articular Injection of Tranexamic Acid Reduced Postoperative Hemarthrosis in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study”

      We read with great interest the recently published article by Chiang et al.
      • Chiang E.-R.
      • Chen K.-H.
      • Wang S.-T.
      • et al.
      Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: A prospective randomized study.
      on the use of tranexamic acid (TXA) in arthroscopic anterior cruciate ligament (ACL) reconstruction. Previously, the drug had been successfully used to control bleeding and reduce total blood loss in non-orthopaedic procedures
      • Joseph J.
      • Martinez-Devesa P.
      • Bellorini J.
      • Burton M.J.
      Tranexamic acid for patients with nasal haemorrhage (epistaxis).
      • Ng W.
      • Jerath A.
      • Wąsowicz M.
      Tranexamic acid: A clinical review.
      ; more recently, several high-quality studies have addressed the use of TXA in joint replacement, and its efficacy in this setting is now widely recognized.
      • Xiong H.
      • Liu Y.
      • Zeng Y.
      • Wu Y.
      • Shen B.
      The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: A meta-analysis of randomized controlled trials.
      • Gianakos A.L.
      • Hurley E.T.
      • Haring R.S.
      • Yoon R.S.
      • Liporace F.A.
      Reduction of blood loss by tranexamic acid following total hip and knee arthroplasty: A meta-analysis.
      • Melvin J.S.
      • Stryker L.S.
      • Sierra R.J.
      Tranexamic acid in hip and knee arthroplasty.
      The benefits of TXA should be studied for other orthopaedic procedures that may take advantage of reduced bleeding, such as closed-joint surgery, in which hemarthrosis is a cause of pain, functional limitation, and difficulty in rehabilitation.
      • Bahl V.
      • Goyal A.
      • Jain V.
      • Joshi D.
      • Chaudhary D.
      Effect of haemarthrosis on the rehabilitation of anterior cruciate ligament reconstruction—Single bundle versus double bundle.
      At first reading, the study by Chiang et al.
      • Chiang E.-R.
      • Chen K.-H.
      • Wang S.-T.
      • et al.
      Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: A prospective randomized study.
      draws great attention because of the number of patients included (304) and its prospective randomized design. However, we consider that more discussion is warranted regarding some of its findings and their clinical relevance.
      Regarding the outcome of drainage volume, despite the statistically significant value, the 24-mL mean difference found between groups did not appear to be clinically significant. This makes it hard to explain the very clinically important difference of 3.5 points in the visual analogue scale score on the third day. Therefore, we raise the question of whether the method chosen to evaluate blood loss was the most adequate.
      There are 2 main reasons we consider drain output an inadequate outcome measure in this setting. First, it is known that knee hemarthrosis after ACL reconstruction may increase in the first few days, not just in the first 24 hours, and probably for this reason, Chiang et al.
      • Chiang E.-R.
      • Chen K.-H.
      • Wang S.-T.
      • et al.
      Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: A prospective randomized study.
      chose to grade the joint effusion on the third day and in the fourth week as well. Second, the use of postoperative drains after ACL reconstruction is not routine in most centers because most patients are discharged on the day of surgery and the use of drains does not appear to have clinical benefit in ACL surgery.
      • McCormack R.G.
      • Greenhow R.J.
      • Fogagnolo F.
      • Shrier I.
      Intra-articular drain versus no drain after arthroscopic anterior cruciate ligament reconstruction: A randomized, prospective clinical trial.
      The clinical implications of TXA use could be remarkably different is a setting in which postoperative drains are not used, so care should be taken in extrapolating these findings to other settings.
      Moreover, keeping the drain closed for the first 2 hours may decrease the total bleeding volume owing to tamponade and clot formation. In addition, TXA in a high intra-articular concentration could lead to the formation of clots in the drain, impairing its outflow and unpredictably affecting the outcome. In this scenario, intravenous drug use would eliminate this risk, as appears to be the case shown in the study by Karaaslan et al.,
      • Karaaslan F.
      • Karaoğlu S.
      • Yurdakul E.
      Reducing intra-articular hemarthrosis after arthroscopic anterior cruciate ligament reconstruction by the administration of intravenous tranexamic acid: A prospective, randomized controlled trial.
      in which intravenous TXA use showed 90-mL less drainage. Therefore, although the 24-hour drained volume is illustrative of the effect of TXA in a scientific study, we believe that it is not a good outcome to measure for intra-articular blood loss after ACL surgery and that these findings may have low external validity for most settings in which a drain is not used.
      Chiang et al.
      • Chiang E.-R.
      • Chen K.-H.
      • Wang S.-T.
      • et al.
      Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: A prospective randomized study.
      briefly discussed the administration route and the use of drains but not to the point that these limitations of the study are clear, so the aim of this letter is to enrich the discussion of these topics. At last, we would like to congratulate the authors for this excellent study, which showed a clinical difference in the visual analog scale score and in the intensity of postoperative hemarthrosis in ACL reconstruction surgery with TXA infiltration.

      Supplementary Data

      References

        • Chiang E.-R.
        • Chen K.-H.
        • Wang S.-T.
        • et al.
        Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: A prospective randomized study.
        Arthroscopy. 2019; 35: 2127-2132
        • Joseph J.
        • Martinez-Devesa P.
        • Bellorini J.
        • Burton M.J.
        Tranexamic acid for patients with nasal haemorrhage (epistaxis).
        Cochrane Database Syst Rev. 2018; 12CD004328
        • Ng W.
        • Jerath A.
        • Wąsowicz M.
        Tranexamic acid: A clinical review.
        Anaesthesiol Intensive Ther. 2015; 47: 339-350
        • Xiong H.
        • Liu Y.
        • Zeng Y.
        • Wu Y.
        • Shen B.
        The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: A meta-analysis of randomized controlled trials.
        BMC Musculoskelet Disord. 2018; 19: 321
        • Gianakos A.L.
        • Hurley E.T.
        • Haring R.S.
        • Yoon R.S.
        • Liporace F.A.
        Reduction of blood loss by tranexamic acid following total hip and knee arthroplasty: A meta-analysis.
        JBJS Rev. 2018; 6e1
        • Melvin J.S.
        • Stryker L.S.
        • Sierra R.J.
        Tranexamic acid in hip and knee arthroplasty.
        J Am Acad Orthop Surg. 2015; 23: 732-740
        • Bahl V.
        • Goyal A.
        • Jain V.
        • Joshi D.
        • Chaudhary D.
        Effect of haemarthrosis on the rehabilitation of anterior cruciate ligament reconstruction—Single bundle versus double bundle.
        J Orthop Surg Res. 2013; 8: 5
        • McCormack R.G.
        • Greenhow R.J.
        • Fogagnolo F.
        • Shrier I.
        Intra-articular drain versus no drain after arthroscopic anterior cruciate ligament reconstruction: A randomized, prospective clinical trial.
        Arthroscopy. 2006; 22: 889-893
        • Karaaslan F.
        • Karaoğlu S.
        • Yurdakul E.
        Reducing intra-articular hemarthrosis after arthroscopic anterior cruciate ligament reconstruction by the administration of intravenous tranexamic acid: A prospective, randomized controlled trial.
        Am J Sports Med. 2015; 43: 2720-2726

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