Study On The Safety And Effectiveness Of Tranexamic Acid In Arthroscopic Synovectomy For Knee Synovitis

Aims:1.To explore the toxicity and cellular functional effects of different concentrations of TXA on human chondrocytes and fibroblast-like synoviocytes in vitro,preliminarily determine the relative safe concentration of TXA in the joint.2.To investigate the safety and efficacy of intra-articular use of different concentrations of TXA in arthroscopic synovectomy for knee synovitis.Methods:1.Toxicity study of TXA on human chondrocytes and fibroblast-like synoviocytes in vitro: Human normal chondrocytes and fibroblast-like synoviocytes at the third passage were harvested and characterized by immunofluorescence,respectively.In this study,we divided the experimental groups into human chondrocyte and human fibroblastlike synoviocyte groups,which were subdivided according to TXA concentrations of 0 mg/m L,10 mg/m L,20 mg/m L,and 40 mg/m L,respectively.Three hours after treatment with TXA at the above concentrations,we examined the toxic effects of TXA on human chondrocytes and fibroblast-like synoviocytes using CCK-8,Calcein-AM/PI live and dead staining,and Annexin V-FITC/PI flow cytometry for apoptosis..Cellular functional studies of TXA on human chondrocytes and fibroblast-like synoviocytes in vitro: The effect of TXA on type II collagen synthesis in human chondrocytes was determined by immunofluorescence staining after 3 hours of TXA treatment at the concentrations described above.At the end of the TXA intervention and 24 hours after the end,the human chondrocyte group was used q PCR to detect the effect of TXA on the m RNA expression of human chondrocyte type II collagen and MMP-13;ELISA method was used to detect the effect of TXA on the content of IL1β and MMP-13 in the supernatant of human chondrocytes.At the same time,these two time points applied q PCR method to detect the effect of TXA on the expression of IL1-β,IL-6 and TNF-α in human fibroblast-like synovial cells;ELISA method was used to detect the effect of TXA on the content of IL1-β,IL-6 and TNF-α in the supernatant of human fibroblast-like synovial cells.2.Safety and efficacy of intra-articular use of TXA in arthroscopic synovectomy of knee synovitis: A prospective double-blind randomized controlled trial was conducted in our centre from April 2019 to October 2020 including 118 patients underwent arthroscopic synovectomy for knee synovitis.Based on the safe concentration of TXA derived from in vitro cell experiments,all patients were randomized into three groups:group A received 10 mg/m L TXA intra-articularly,group B received 20 mg/m L TXA intra-articularly and the control group received no TXA.After the synovial lesion was completely removed by the surgeon,1 drainage tube was placed in the knee joint cavity,and 50 m L of TXA solution with concentrations of 10 mg/m L and 20 mg/m L was injected into the joint cavity of groups A and B,respectively,while no solution was injected into the control group before clamping the tube.The drainage tube was opened again 3 hours after operation.The main postoperative observation indicators were: Changes in the total drainage volume of patients 4h,12 h,24h and before extubation,total blood loss and changes in hematology(inflammatory indexes,hemoglobin,etc.)related indexes at 24 h after operation,and the pain scores,knee joint mobility and function of patients during the postoperative 3-month period.The occurrence of adverse events such as thrombosis,infection,and hemarthrosis after TXA use in each group was recorded.Results:1.Toxicity studies of TXA in human chondrocytes and fibroblast-like synoviocytes in vitro: Results of CCK-8 test showed that TXA solution of 40 mg/m L significantly reduced the proliferation rate of human chondrocytes and fibroblast-like synoviocytes,compared with 0 mg/m L,10 mg/m L and 20 mg/m L(P < 0.05).However,there was no statistically significant difference in the proliferation rate of human chondrocytes and fibroblast-like synovial cells among the three groups of 0 mg/m L group,10mg/m L group and 20 mg/m L group(P<0.05).As assessed by live and dead staining and flow cytometry,the number of cell deaths and apoptotic rate of human chondrocytes and fibroblast-like synoviocytes was significantly higher than the other two groups(P < 0.05).However,there was no significant difference in the apoptosis rate of human chondrocytes and fibroblast-like synovial cells among the three groups of 0 mg/m L group,10 mg/m L group and 20 mg/m L group(P<0.05).Cellular function studies of TXA on human chondrocytes and fibroblast-like synoviocytes in vitro: The results of type II collagen immunofluorescence intensity on human chondrocytes showed a significant reduction in the amount of collagen expressed by human chondrocytes at 40mg/m L(P<0.05).q PCR of human chondrocytes showed that at the end and 24 hours after the end of the intervention,the m RNA expression level of type II collagen of human chondrocytes in the 40mg/m L group was significantly lower than that in the other three groups(P<0.05).The m RNA expression level of MMP-13 was significantly higher than that in the other three groups(P<0.05).Significantly decreased m RNA expression levels of IL-1β of human fibroblast-like synoviocytes in the 20 mg/m L and 40 mg/m L groups at the end of the intervention were observed(P>0.05).The m RNA expression levels of IL-1βand IL-6 were significantly reduced in the 40 mg/m L group compared to the other three groups at 24 hours after the end of the intervention(P<0.05).The levels of MMP-13 in the supernatants of human chondrocyte of the 40 mg/m L group increased significantly at the end and 24 hours after the end of the intervention(P<0.05).The levels of IL-1β,IL-6 and TNF-α in the supernatants of human fibroblast-like synoviocytes were comparable between groups at the end and 24 hours after the end of the intervention(P>0.05).2.The safety and efficacy study of the intra-articular use of TXA in arthroscopic synovectomy for knee synovitis: Basic demographic characteristics of patients were consistent between three groups.In terms of postoperative drainage: compared with the control group,the drainage volume of group A and B at 4 hours,12 hours and 24 hours after operation and the total drainage volume after operation were significantly reduced,with 183.9 ± 104.2 m L of control group,49.0 ± 24.2 m L of group A,and54.1 ± 27.8 m L of group B(P<0.05).Compared with the total blood loss of0.279±0.130 L of control group,group A and B presented significantly reduced total blood loss at 24 h postoperation,which was 0.214 ± 0.131 L and 0.192 ± 0.087 L respectively.There was no statistically significant difference between the inflammatory indexes IL-6 and CRP before and 24 h after operation.In terms of pain scores of knee,group A and B had significantly lower VAS scores compared with the control group at 12 hours,1 day,3 days,and 14 days postoperatively(P<0.05).After1 month of surgery,there was no significant difference in knee VAS scores between groups(P>0.05).Knee joint function related indicators: the knee joint range of motion(ROM),Lysholm score and knee joint circumference in groups A and B were significantly better than those in the control group 3 days after operation and 14 days after operation,and the difference was statistically significant(P<0.05).The Lysholm scores of 14 days after operation were 66.8 ± 3.4 in the control group,80.4 ± 4.2 in group A,and 80 ± 4.6 in group B.However,there were no significant differences in knee function indicators at all time points between group A and B(P>0.05).In terms of adverse effects: group A and B did not show any increased rate of complications,such as thrombosis,knee hemarthrosis and infection,compared with the control group.Conclusions:1.TXA has toxic effects on human normal chondrocytes and fibroblast-like synoviocytes in vitro,and its toxicity directly correlates with increasing concentrations.At an intervention time of 3 hours,TXA concentrations no higher than20 mg/m L were relatively safe for human chondrocytes and fibroblast-like synoviocytes in vitro.2.The intra-articular use of TXA significantly reduced joint drainage,perioperative blood loss and early pain after arthroscopic resection of diseased synovium in knee synovitis,while promoting the recovery of knee joint function in the early postoperative period without increasing the risk of complications.