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Topical Tranexamic Acid and Floseal® in Total Knee Arthroplasty

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ClinicalTrials.gov Identifier: NCT02865174
Recruitment Status : Unknown
Verified August 2016 by Wang Jun-Wen, Chang Gung Memorial Hospital.
Recruitment status was:  Not yet recruiting
First Posted : August 12, 2016
Last Update Posted : August 12, 2016
Sponsor:
Information provided by (Responsible Party):
Wang Jun-Wen, Chang Gung Memorial Hospital

Brief Summary:
Our purpose of this study is to conduct a prospective randomized controlled trial to investigate the blood-conservation effect of this two topical hemostatic agents in primary TKA procedures in patients with a risk of thromboembolic events. We will also observe if there is increased risk of thromboembolism by use of topical hemostatic agents.

Condition or disease Intervention/treatment Phase
Osteoarthritis, Knee Drug: Topical tranexamic acid Drug: Floseal® Drug: Enoxaparin Phase 4

Detailed Description:

Total knee arthroplasty (TKA) is associated with considerable blood loss and increasing needs for allogenic blood transfusion. Previous studies demonstrated a transfusion rates ranging from 10% to 38% after standard TKAs. Transfusion carries significant risks of cardiopulmonary embarrassment, disease transmission, immunological reaction and postoperative infection.

The major causes of postoperative blood loss following TKA are attributed to surgery itself which induces a considerable activation of the coagulation cascade and local fibrinolysis, the latter is further enhanced after release of the tourniquet at the end of surgery. Tranexamic acid (TXA), an inhibitor of fibrinolysis, was reportedly effective reducing blood loss after standard TKA. Our previous experiences in minimally invasive (MIS) TKA showed that intraoperative infusion of TXA reduced 45% of postoperative blood loss and needs for transfusion from 20% to 4%. However, most of the orthopedic surgeons still hesitate to use TXA systemically in TKAs especially in high risk patients with a potential increase in thromboembolic events following surgery. A recent study by Nishihara et al demonstrated that use of TXA in total hip arthroplasty did not appear to affect the prevalence of either proximal DVT or PE. Another study by Xie J et al also showed the incidence of postoperative VTE was unchanged when TXA was administered in primary unilateral TKA, but in there study the total occurrence of vascular occlusive events was statistically significantly higher (17.55% Vs 9.35%, p < 0.001) in the TXA group. However, in this two studies the patient with high risk of thromboembolic events (ischemic heart disease, chronic renal failure on hemodialysis, cerebral infarction, previous VTE disease, thrombophilia associated with genetic diseases) were excluded.

We believe the topical use of hemostatic agent in patients with high risk of thromboembolism can avoid its systematic effect and decrease its potential perioperative risk of thromboembolic complications (arterial thrombosis, myocardial infarction and pulmonary embolism). Recently, there were some reports demonstrating the cost-effectiveness of topical application of TXA in TKA patients. Besides, thrombin-based hemostatic agents, Floseal®, have been widely used in surgical procedure including gynecology, general surgery, and orthopedics which were still attracting the attention and interest of multitudinous surgeons. Some recent studies demonstrated that topic use of Floseal® in primary TKA can reduce hemoglobin decline and calculated total blood loss after TKA and is not related to adverse reactions or complications such as wound infection, venous thromboembolism events(VTE). But there were another studies showed Floseal® does not reduce blood loss in TKA procedures.

Our purpose of this study therefore is to conduct a prospective randomized controlled trial to investigate the blood-conservation effect of this two topic hemostatic agents and their safety in a primary TKA procedures in patients with risk of thromboembolic events. The first group by topical TXA application, the second group by topical Floseal® application, and the third group of placebo and observe whether there is difference in the the blood-conservation effect by total blood loss calculation, hemoglobin loss and transfusion requirement among these patient groups.


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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 90 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Participant)
Primary Purpose: Prevention
Official Title: Comparison of Topical Tranexamic Acid and Floseal® on Blood Loss After Total Knee Arthroplasty in Patients With a Thromboembolic Risk
Study Start Date : September 2016
Estimated Primary Completion Date : August 2017
Estimated Study Completion Date : August 2017

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Active Comparator: Topical tranexamic acid
Intraarticular application of tranexamic acid Enoxaparin for venous thromboembolism prophylaxis in the duration of hospital stay
Drug: Topical tranexamic acid
Intraarticular application of tranexamic acid 3g in 100 ml normal saline into knee joint after closure of the joint capsule
Other Name: Topical transamine

Drug: Enoxaparin
Enoxaparin will be administrated sc 40mg each day postoperatively as venous thromboembolism prophylaxis in the duration of hospital stay
Other Name: Low molecular weight heparin

Active Comparator: Floseal®

Floseal® was applied on potential bleeding sites before prosthesis implantation.

Enoxaparin for venous thromboembolism prophylaxis in the duration of hospital stay

Drug: Floseal®
Floseal® (Hemostatic matrix, 10ml, Baxter) was applied on potential bleeding sites: the femoral insertion of the posterior cruciate ligament, the lateral genicular artery after resection of the meniscus, the posterior capsule of the knee joint, the bony surfaces not covered by the implant as well as the pinholes (femur and tibia). The entire content of a 10 mL vial containing the active product (Floseal®) was used. The HM remained in place for 3 minutes and was then gently rinsed from the knee as recommended by the manufacturer (Baxter)
Other Name: Thrombin-gelatin matrix

Drug: Enoxaparin
Enoxaparin will be administrated sc 40mg each day postoperatively as venous thromboembolism prophylaxis in the duration of hospital stay
Other Name: Low molecular weight heparin

Placebo Comparator: Control group
No intervention before closure of joint capsule. Enoxaparin for venous thromboembolism prophylaxis in the duration of hospital stay
Drug: Enoxaparin
Enoxaparin will be administrated sc 40mg each day postoperatively as venous thromboembolism prophylaxis in the duration of hospital stay
Other Name: Low molecular weight heparin




Primary Outcome Measures :
  1. Total blood loss after operation [ Time Frame: From the operation to the postoperative day 3 or 4 ]
    Total blood loss was calculated according to Nadler et al., which used maximum postoperative reduction of the Hb level adjust for weight and height of the patient. The formula is as follows, Total blood loss = (Total blood volume x [change in Hb level / preoperative Hb level])x1000+volume transfused

  2. Decrease of hemoglobin level after operation [ Time Frame: From the operation to the postoperative day 14 ]
    We will check hemoglobin preoperatively and postop. Day 1, 2, 3 or 4 and 14. We will calculate the change of hemoglobin level on postoperative day 1, 2, 4, and 14.


Secondary Outcome Measures :
  1. Incidence of major postoperative bleeding [ Time Frame: within 30 days of the operation ]
    Major bleeding was defined as bleeding that involved a critical organ, or that required reoperation or clinically overt bleeding outside the surgical site that was associated with a decrease in the hemoglobin level of 2 g or more per deciliter or requiring infusion of 2 or more units of blood

  2. Incidence of any non-major bleeding [ Time Frame: within 30 days of the operation ]
    Non-major bleeding including hemorrhagic wound complications (excessive wound hematoma or bleeding at the surgical site

  3. Incidence of wound infection after surgery [ Time Frame: within 30 days of the operation ]
    composite of wound poor healing, superficial wound infection, and deep infection requiring return to surgery

  4. Incidence of any thrombotic events [ Time Frame: within 30 days of the operation ]
    the composite of any venous thromoembolism events, ischemic heart attacks, cerebrovascular accidents



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Ages Eligible for Study:   50 Years to 85 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   Yes
Criteria

Inclusion Criteria:

History of ischemic heart disease, stroke, or VTE high risk group, such as obesity, varicose vein of the leg, previous history of PE or DVT, hypercoagulability, recent or ongoing treatment for cancer.

After cardiologist or neurologist's evaluation, patients who was classified as low-risk of perioperative risk Advanced knee osteoarthritis, Failure of medical treatment or rehabilitation. Hemoglobin > 11g/dl, No use of non-steroid anti-inflammatory agent one week before operation

Exclusion Criteria:

Preoperative Hemoglobin ≦11 g/dl History of infection or intraarticular fracture of the affective knee Renal function deficiency (GFR < 30 ml/min/1.73m2) Elevated liver enzyme, history of liver cirrhosis, impaired liver function and coagulopathy


Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02865174


Contacts
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Contact: Jun-Wen MD Wang 886-7-7317123 wangjw@adm.cgmh.org.tw

Locations
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Taiwan
Kaohsiung Chang Gung Memorial Hospital
Koahsiung, Taiwan
Sponsors and Collaborators
Chang Gung Memorial Hospital
Investigators
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Study Chair: Jun-Wen Wang Chang Gung Memorial Hospital

Publications:

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Responsible Party: Wang Jun-Wen, Wang Jun-Wen [wang0155], Chang Gung Memorial Hospital
ClinicalTrials.gov Identifier: NCT02865174     History of Changes
Other Study ID Numbers: NMMRPG8F0191
First Posted: August 12, 2016    Key Record Dates
Last Update Posted: August 12, 2016
Last Verified: August 2016
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

Keywords provided by Wang Jun-Wen, Chang Gung Memorial Hospital:
Thrombin-gelatin matrix
Floseal
Tranexamic Acid
Total Knee Arthroplasty

Additional relevant MeSH terms:
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Osteoarthritis
Osteoarthritis, Knee
Arthritis
Joint Diseases
Musculoskeletal Diseases
Rheumatic Diseases
Tranexamic Acid
Thrombin
Heparin, Low-Molecular-Weight
Dalteparin
Antifibrinolytic Agents
Fibrin Modulating Agents
Molecular Mechanisms of Pharmacological Action
Hemostatics
Coagulants
Anticoagulants
Fibrinolytic Agents