Combination of Intravenous and Intra-Articular Application of Tranexamic Acid and Epsilon-Aminocaproic Acid in Primary Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

ObjectiveThere were limited randomized controlled trials (RCTs) of epsilon-aminocaproic acid (EACA) versus tranexamic acid (TXA) in total knee arthroplasty (TKA). The aim of the study was to compare the efficacy and safety of TXA and EACA in the combination of intravenous (IV) and intra-articular (IA) administration on reducing blood loss in patients following primary TKA. MethodsFrom January 2020 to January 2021, a total of 181 patients undergoing a primary unilateral TKA were enrolled in this prospective randomized controlled trial. Patients in the TXA group (n = 90) received 20mg/kg of intravenous TXA preoperatively, 1g of intra-articular TXA intraoperatively, and three doses of 20mg/kg intravenous TXA at 0, 3, 6h postoperatively. Patients in the EACA group (n = 91) received 120mg/kg of intravenous EACA preoperatively, 2g of intra-articular EACA intraoperatively, and three doses of 40mg/kg intravenous EACA at 0, 3, 6h postoperatively. The primary outcomes were total blood loss (TBL), transfusion rates and drop of hemoglobin (HB) level. The secondary outcomes included postoperative hospital stays and postoperative complications. The chi-square tests and Fisher's exact tests were utilized to compare categorical variables, while the independent-samples t-tests and Mann-Whitney tests were used to compare continuous variables. ResultsThe patients who received TXA averaged less TBL than the patients who received EACA (831.83ml vs 1065.49ml, P = 0.015), and HB drop in TXA group was generally less than that of EACA group on postoperative day 1 and 3 (20.849.48g/L vs 24.99 +/- 9.40g/L, P = 0.004; 31.28 +/- 11.19 vs 35.46 +/- 12.26g/L, P = 0.047). The length of postoperative stays in EACA group was 3.66 +/- 0.81 day, which is longer than 2.62 +/- 0.68 day in TXA group (P<0.001). No transfusions were required in either group. The risk of nausea and vomiting in TXA group was significantly higher than that in EACA group (11/90 vs 0/91, P<0.01). ConclusionAlthough the TBL and HB drop were slightly greater in EACA group, these results were not clinically important, given that no transfusions were required. EACA could be an alternative to TXA, especially for patients with severe nausea and vomiting after using TXA postoperatively. Further studies are needed to adjust dosage of EACA to make better comparison of the two drugs.