| Background:It is an important method for Total knee arthroplasty(TKA)to be the treatment of knee osteoarthritis.The curative effect is optimal,but TKA is difficult to be populize because of the blood loss caused by the operations,the hemoglobin can be decreased continuously for several days after operation,The purpose of this paper is to explore ways to reduce the blood loss caused by TKA.Objective:1.To investigate the influential factors related to perioperative blood loss in total knee arthroplasty(TKA).2.To discuss the effect of different usage of tranexamic acid(TXA)on blood loss of TKA in different time.3.To investigate the TXA’s protective effect and appropriate time of administration on impaired human umbilical vein endothelial cells(HUVECs)caused by H2O2.Explain the chronergy of TXA discovred in clinical studies.Materials and methods:1.Materials:322 knee osteoarthritis(OA)patients underwent TKA were enrolled in the study.Their clinical data were retrospectively studied,including preoperative,intraoperative and postoperative date,In addition to routine data,all patients had the usage of TXA,intercondylar osteotomy of intercondylar femur during operation,the femoral location hole plugging,use of Haemocoagulase Agkistrodon for after operation,use of anticoagulants,etc.And all the patients had the result of routine blood before and after operation on the 1st,3rd and 5th day after operation.Method:(1)Gross formula was used to estimate the blood loss,the blood loss at 1st day,3rd day,5th day after operation and the blood loss between 1st and 3rd day,3rd and 5th day post-operatively were included.(2)Multivariate linear regression analysis were performed,in which the dependent variables were blood loss volume at different period.22 potential influential factors were included as independentvariables.2.Based on the different usage of TXA,patients were divided into four groups:group A(without application),group B(topical application),group C(intravenous application)and group D(combined application).We compared the effect at different period after operation.The blood loss at 1st day,3rd day,5th day after operation and the blood loss between 1st and 3rd day,3rd and 5th day post-operatively,and other factors were included.3.In vitro Human umbilical vein endothelial cells(HUVECs)were exposed to H2O2 and TXA was added in different time respectively.The cellular morphology was observed using a fluorescence microscope after Hoechst 33258 staining.The damage of endothelial cell was evaluated by ICAM,MMP-9 expression,syndecan concentration,tissue-type plasminogen activator(tPA),plasminogen activator inhibitor-1(PAI-1),Hyaluronic acid,Tumor necrosis factor-a(TNF-a)concentration.Result:1.(1)The theoretical blood loss was the highest on 3rd day after operation.(2)4 factors including TXA,gender,drain and anticoagulation drugs were proved to be correlated with the blood loss in TKA.①without application of TXA were positive factors on the 1st,3rd,5th,3rd～5th day after operation.② male were positive factors on the 1st,3rd,1rd～3th day after operation,and were negative factors on the 3rd～5th day after operation.③with drainage was a positive factor on the 1st,3rd,5rd day after operation.④Low molecular weight heparin(LMWH)was negative factors on 1st～3rd days and positive factors on 3rs～5th days after operation.2.The same result was present both in 1st day and 3rd day after operation.Group A suffered more blood loss than the rest groups(all p<0.05).Group B suffered more blood loss than group D(p<0.05),while group B and group C,group C and group D showed no significant difference.In the 5th day,patients in group A suffered the most blood loss(all p<0.05),following by group B.Group C suffered less blood loss than group B while more than group D(all p<0.05).For the continuous blood loss between 1st and 3rd day,group A suffered more blood loss than group B(p<0.05).Group C suffered more blood loss than group B(p<0.05).The rest showed no significant difference.During 3 rd to 5th day,apart from group B suffered more blood loss than both group C and group D(both p<0.05),no significant difference was present for the rest comparision.3.Exposure of HUVECs to H2O2 resulted in promoted apoptosis which is present with increased levels of ICAM,MMP-9 expression,syndecan and tPA,Hyaluronic acid,TNF-α,and inhibited expression of PAI-1.The above process can be effectively inhibited by TXA in early 15 minutes.There is no such effect above in later administration.Conclusion:1.(1)Hb decreased by an average of three days after TKA(2)①The application of TXA in TKA can reduce the blood loss and the effect is lasting between 3rd and 5th days after operation,this persistent effect needs to be further explored.②Male has a risk suffering more blood loss than female within 3 days after operation,But there was no difference in blood loss between male and female on the 5th day after operation.③The blood loss caused by low-molecular-weight heparin between 1st and 3rd days was less than that caused by rivastaban,But there was no difference between them on the 5th day after operation.④Drainage may increase the postoperative bleeding,And blood loss was concentrated within 12 hours after the operation.⑤intercondylar osteotomy of intercondylar femur during operation executed or not,the femoral location hole plugging executed or not,Haemocoagulase Agkistrodon be used or not after operation and other factors can’t affect the postoperative blood loss.2.Both intravenous and intraarticular application of TXA can effectively reduce blood loss after TKA and the combined application is superior to single application.A continuous effect was found in intravenous application in 3rd to 5th days after operation,which is better than that in topical application.It was further revealed that the persistence of TXA in the first part of the study was mainly due to intravenous use.3.Fibrinolysis and other protective effects of TXA administration on endothelial injury are time-dependent,It can inhibit the degradation of polysaccharide protein complex in HUVECs induced by H202.Early application of TXA is recommended in clinical practice.The late effect of TXA in the first two parts of clinical study can be explained by this kind of protection,and it can be further studied. |
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