Reducing Postoperative Anemia and Enhancing Postoperative Recovery in TKA: Exploring the Synergistic Effects of Tranexamic Acid and Absorbable Hemostat

Commentary In total knee arthroplasty (TKA), bleeding and postoperative anemia have long been concerns. The introduction of tranexamic acid (TXA) has reduced postoperative bleeding, making transfusions almost unnecessary1. TXA can also be used safely in patients with a history of venous thromboembolism2. TXA is now strongly recommended by the American Academy of Orthopaedic Surgeons (AAOS) in their clinical practice guidelines3 and has become the standard of care. If transfusion avoidance is the primary goal, TXA alone is sufficient. However, with increasing demands for shorter hospital stays and same-day discharge after surgery, the next step is to focus on early postoperative recovery, which has led to investigations into various approaches. Postoperative anemia can delay recovery and increase the risk of complications4. We have now entered an era in which avoiding not only transfusion but also postoperative anemia is essential. The study by Zhang et al. thoroughly examined the combined effects of TXA and absorbable hemostat (AH), which have different mechanisms for reducing postoperative bleeding, through in vivo and in vitro experiments and a randomized controlled trial. The combination of TXA and AH reduced perioperative blood loss more effectively than either agent alone. However, since only 1 patient required a transfusion across all groups, no significant difference in transfusion rates was observed. Laboratory results showed that the combination had no impact on inflammatory markers or coagulation function, except for postoperative platelet counts. Additionally, no obvious clinical complications were observed with the addition of AH to TXA. A noteworthy finding was that the combination of TXA and AH resulted in a higher proportion of patients maintaining normal hemoglobin levels postoperatively compared with other groups. The combination group had no cases of moderate or severe anemia. Additionally, this group demonstrated less knee swelling by postoperative day 1, higher Hospital for Special Surgery (HSS) knee scores by postoperative day 3, and faster walking speeds maintained through day 21. These results suggest that the combination of TXA and AH reduces the incidence of postoperative anemia and contributes to early recovery. The results of this study may vary depending on the TXA dosage, the route of administration, the use of a tourniquet, the type and volume of AH, and patient race. Future challenges include determining the optimal dosing and administration method. Moreover, understanding the scientific mechanisms by which avoiding postoperative anemia leads to early recovery, as well as evaluating outcomes with use of clinical scores beyond the HSS score, will be important future research goals. The sample size in this study was insufficient to draw firm conclusions regarding complications, warranting careful evaluation in future research. Additionally, it is necessary to assess the balance between the increased cost of adding AH to standard TXA treatment and the potential reduction in perioperative costs due to faster recovery. Since it remains unclear whether AH should be used in all patients undergoing TKA, further studies are needed to establish the appropriate indications and contraindications for the combined use of TXA and AH. The combination of TXA and AH holds promise as a strategy for reducing postoperative anemia and contributing to early recovery in TKA. Moving forward, reports from other institutions are eagerly awaited to validate these findings.