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Intraoperative tranexamic acid reduces postoperative haemarthrosis and improves early functional outcomes in double-bundle anterior cruciate ligament reconstruction
⁎Corresponding author: Zhe-Yu Huang. nb_joint@163.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Double-bundle anterior cruciate ligament reconstruction (ACLR) has biomechanical advantages but is associated with increased intraoperative bleeding. The role of tranexamic acid (TXA) in reducing postoperative joint haemarthrosis and improving the short-term outcomes of double-bundle ACLR has not yet been thoroughly investigated. This study aimed to assess the effects of intraoperative TXA on postoperative joint haemarthrosis and short-term functional outcomes in patients who underwent double-bundle ACLR.
This retrospective cohort study included 80 male patients who underwent double-bundle ACLR between January 2019 and December 2022. The patients were divided into two groups: those who received TXA and those that did not. The TXA group received 50 mL of TXA (10 mg/mL) intravenously approximately 10 min before tourniquet release, followed by an intra-articular injection of 50 mL TXA (10 mg/mL) immediately after wound closure, prior to tourniquet release, whereas the control group did not receive TXA. Primary outcomes included postoperative haemarthrosis volume, assessed using Coupens and Yate (CY) values; and short-term functional recovery, evaluated using range of motion (ROM), quadriceps strength, and visual analogue scale (VAS) pain scores on day 1, day 15, week 6, and week 12 postoperatively.
Intraoperative administration of TXA in patients undergoing double-bundle ACLR reduced postoperative haemarthrosis, as measured by a lower CY value on postoperative day 1 (P = 0.004) and day 15 (P < 0.001). Compared to patients in the control group, patients in the TXA group reported lower VAS pain scores on day 1 (P < 0.001), day 15 (P < 0.001), and week 6 (P = 0.028), together with improved quadriceps strength (P = 0.043, day 1; P = 0.009, day 15) and ROM (P < 0.001, 12 weeks postoperatively) during the early postoperative period.
The use of TXA during double-bundle ACLR may reduce postoperative joint haemarthrosis and enhance short-term functional outcomes.
Keywords
Tranexamic acid
Anterior cruciate ligament reconstruction
Haemarthrosis
1 Introduction
Anterior cruciate ligament (ACL) injuries are among the most prevalent knee injuries, particularly in young and active individuals, with an estimated annual incidence rate of 38–78 per 100,000 individuals.1 These injuries often result in marked functional impairment and a high risk of osteoarthritis if left untreated. Surgical reconstruction is the primary method for restoring knee stability and function, with ACL reconstruction (ACLR) being the most common procedure.2–4 The main approaches to ACLR include single- and double-bundle techniques.5–7 Double-bundle ACLR aims to better replicate the natural anatomy and biomechanics of the ACL, providing superior rotational stability compared to single-bundle reconstruction.8
The double-bundle ACLR technique involves reconstructing both the anteromedial and posterolateral bundles of the ACL, which play crucial roles in controlling tibial rotation and maintaining overall knee stability.8,9 This method offers biomechanical advantages over single-bundle reconstruction, including improved control of rotational forces and more accurate restoration of knee kinematics.10 However, the increased surgical complexity of the double-bundle technique increases the risk of intraoperative bleeding and postoperative joint haemarthrosis, which can result in substantial complications, such as pain, swelling, and delayed rehabilitation.7 To mitigate these risks, the antifibrinolytic agent, tranexamic acid (TXA), has been proposed to reduce blood loss and minimise postoperative haemarthrosis.6,11 TXA functions by inhibiting the activation of plasminogen to plasmin, thereby preventing the breakdown of fibrin clots and stabilising the formed clots.12 It has been widely used in various orthopaedic procedures, including total knee arthroplasty and hip replacement, and effectively reduces intraoperative and postoperative blood loss, decreases the need for blood transfusions, and reduces the incidence of haemarthrosis.6,13 In the context of ACLR, TXA has shown promise in reducing postoperative haemarthrosis, particularly in single-bundle procedures, where it has been associated with lower drainage volumes and better early-postoperative outcomes.11,14 However, the application of TXA in double-bundle ACLR, in which the risk of bleeding is inherently higher owing to increased surgical complexity, remains underexplored.
Given the potential benefits of TXA in controlling bleeding, this study aimed to evaluate its impact on postoperative joint haemarthrosis and short-term functional outcomes after double-bundle ACLR. By comparing patients who underwent TXA with those that did not, this study aimed to provide evidence to inform clinical decision-making and optimise recovery strategies for this complex surgical procedure.
2 Material and methods
2.1 Study design
This retrospective cohort study focused on patients who underwent double-bundle ACLR between January 2019 and December 2022. Ethical approval was obtained from the institutional review board, and all patient data were handled in compliance with standard confidentiality and ethical guidelines. This study included patients aged 18–45 years who underwent primary double-bundle ACLR. The exclusion criteria were: (1) history of knee surgery on the affected limb, (2) known coagulation disorders, (3) renal insufficiency, and (4) other important comorbidities that could influence surgical outcomes. Patients who did not adhere to the standard postoperative follow-up protocol were excluded from the analysis (Fig. 1).
2.2 TXA administration
The patients were divided into two groups based on the administration of TXA. The TXA group received 50 mL TXA (10 mg/mL) intravenously approximately 10 min before tourniquet release, followed by an intra-articular injection of 50 mL TXA (10 mg/mL) immediately after wound closure prior to tourniquet release. Patients in the control group did not receive TXA.
2.3 Surgical technique
The surgeries were performed by three experienced senior surgeons. All patients underwent general anaesthesia induction with the routine application of a pneumatic tourniquet. Autologous semitendinosus tendons were harvested from the same side and prepared using a folding and weaving technique along with two allogeneic tendons that were folded and woven for implantation. Briefly, a 3-cm incision was made medially on the proximal tibia, allowing access to the semitendinosus and gracilis tendons. The tendons were woven using 1# Ethibond suture (Ethicon, Somerville, NJ, USA), a type of absorbable suture manufactured by Johnson & Johnson. The diameter of the folded grafts was measured using a graduated cylinder with an incremental size variations of 0.5 mm. The tibial tunnel was created using an Acufex guide (Smith & Nephew, Andover, MA, USA) to ensure that the intramedullary diameter matched that of the folded grafts. Grafts were secured at the femoral site using an EndoButton loop plate (Smith & Nephew, Memphis, TN, USA). At the tibial site, the grafts were fixed with a PEEK screw while the knee was positioned at 30° of flexion.
2.4 Outcome measures
The primary outcomes assessed were volume of postoperative haemarthrosis and short-term functional recovery. The volume of haemarthrosis was assessed using Coupens and Yate (CY) values, which were measured on postoperative day 1, day 15, and week 6. The severity of haemarthrosis was graded using the CY scale (Table 1),15 with grades ranging from 0 (no detectable fluid) to 4 (tense haemarthrosis). Functional recovery was evaluated using range of motion (ROM), quadriceps strength (Table 2), visual analogue scale (VAS) pain scores, and Lysholm scores, which were assessed at multiple postoperative intervals, including day 1, day 15, week 6, and week 12.
| Score | Description |
| 0 | No detectable fluid |
| 1 | Fluid present with fluid wave |
| 2 | Palpable fluid in suprapatellar space |
| 3 | Ballotable patella |
| 4 | Tense haemarthrosis |
| Score | Description |
| 0 | No quadriceps contraction |
| 1 | Quadriceps contraction |
| 2 | Leg movement on same plane, not against gravity |
| 3 | Leg movement against gravity, not against resistance |
| 4 | Lower quadriceps strength |
| 5 | Normal strength |
2.5 Statistical analyses
Statistical analyses were performed using SPSS software version 26.0. Continuous variables were expressed as means ± standard deviations and categorical variables were presented as frequencies and percentages. Independent t-tests were used to compare continuous variables between the TXA and control groups, whereas chi-squared tests were used to compare categorical variables. A P-value <0.05 was considered statistically significant.
3 Results
3.1 Demographic and preoperative clinical data
Eighty male patients were included in this study and equally divided into the TXA (n = 40) and control groups (n = 40). The two groups were comparable in terms of demographic and preoperative clinical characteristics (Table 3). The mean age was similar between the groups (TXA: 28.4 ± 7.4 years, control: 28.0 ± 6.8 years, P = 0.894). The body mass index was also comparable (TXA: 25.1 ± 2.7, control: 25.0 ± 4.0, P = 0.858). Preoperative clinical measures, including thigh and calf circumference, ROM, VAS pain score, and Lysholm score, were not statistically different between the groups, indicating balanced baseline characteristics.
| Demographic data | TXA Group (n = 40) | Control Group (n = 40) | P-value |
| Age, y | 28.4 ± 7.4 | 28.0 ± 6.8 | 0.894 |
| Male/female | 40/0 | 40/0 | >0.999 |
| Body Mass Index | 25.1 ± 2.7 | 25.0 ± 4.0 | 0.858 |
| Acute (<45 d), yes/no | 31/9 | 28/12 | 0.446 |
| Preoperative clinical data | |||
| Thigh circumference, cm | 50.2 ± 4.4 | 50.8 ± 5.4 | 0.596 |
| Calf circumference, cm | 37.3 ± 2.9 | 37.0 ± 3.4 | 0.726 |
| ROM | 98.3 ± 8.6 | 99.0 ± 9.6 | 0.714 |
| VAS score | 2.0 ± 2.1 | 1.8 ± 2.0 | 0.585 |
| Lysholm score | 60.4 ± 20.4 | 61.4 ± 14.4 | 0.700 |
3.2 Postoperative haemarthrosis
The volume of postoperative haemarthrosis was substantially lower in the TXA group than in the control group at multiple postoperative time points (Table 4). On postoperative day 1, the CY value, indicative of haemarthrosis severity, was lower in the TXA group (1.6 ± 0.9) than in the control group (2.1 ± 0.9, P = 0.004). This trend persisted on day 15, with the TXA group showing a lower CY value (1.5 ± 0.9) than the control group (2.3 ± 1.0, P < 0.001). By week 6, the difference in CY values between the two groups had diminished and was not statistically significant (TXA: 0.8 ± 0.8 vs. control: 1.0 ± 0.9, P = 0.540) (Fig. 2A).
| TXA Group (n = 40) | Control Group (n = 40) | P Value | |
| Day 1 after surgery | |||
| Thigh circumference, cm | 51.7 ± 5.7 | 52.0 ± 4.8 | 0.798 |
| Calf circumference, cm | 38.0 ± 3.6 | 39.1 ± 3.2 | 0.155 |
| CY value | 1.6 ± 0.9 | 2.1 ± 0.9 | 0.004 |
| VAS score | 2.5 ± 0.7 | 4.8 ± 1.0 | <0.001 |
| Fever episodes, yes/no | 0/40 | 3/37 | 0.991 |
| Quadriceps Strength | 2.7 ± 0.5 | 2.4 ± 0.6 | 0.043 |
| Day 15 after surgery | |||
| Thigh circumference, cm | 50.9 ± 5.4 | 50.9 ± 4.6 | >0.999 |
| Calf circumference, cm | 37.1 ± 3.2 | 38.1 ± 3.0 | 0.151 |
| CY value | 1.5 ± 0.9 | 2.4 ± 1.1 | <0.001 |
| Range of Motion, deg | 74.8 ± 3.6 | 69.4 ± 5.0 | <0.001 |
| VAS score | 1.3 ± 0.5 | 2.0 ± 1.1 | <0.001 |
| Fever episodes, yes/no | 0/40 | 0/40 | >0.999 |
| Quadriceps Strength | 3.9 ± 0.5 | 3.3 ± 0.9 | 0.009 |
| Week 6 after surgery | |||
| Thigh circumference, cm | 50.7 ± 5.4 | 50.2 ± 4.5 | 0.677 |
| Calf circumference, cm | 36.9 ± 3.2 | 37.4 ± 3.1 | 0.501 |
| CY value | 0.8 ± 0.8 | 1.0 ± 0.9 | 0.540 |
| Range of Motion, deg | 100.0 ± 5.3 | 96.2 ± 5.5 | 0.030 |
| VAS score | 0.8 ± 0.7 | 1.8 ± 0.7 | 0.028 |
| Lysholm score | 83.8 ± 12.0 | 80.2 ± 11.8 | 0.590 |
| Quadriceps Strength | 4.2 ± 0.2 | 4.2 ± 0.4 | 0.780 |
| Week 12 after surgery | |||
| Thigh circumference, cm | 50.7 ± 5.4 | 50.0 ± 4.3 | 0.507 |
| Calf circumference, cm | 36.9 ± 3.2 | 37.0 ± 2.9 | 0.855 |
| CY value | 0.3 ± 0.4 | 0.4 ± 0.4 | 0.600 |
| Range of Motion, deg | 110.1 ± 4.7 | 105.3 ± 4.9 | <0.001 |
| VAS score | 0.0 ± 0.0 | 0.1 ± 0.3 | 0.079 |
| Lysholm score | 98.5 ± 2.1 | 98.0 ± 6.8 | 0.782 |
| Quadriceps Strength | 4.8 ± 0.8 | 4.7 ± 0.8 | 0.832 |
3.3 Pain and functional outcomes
Pain levels, as measured using the VAS, were substantially reduced in the TXA group across all measured time points (Table 4). On postoperative day 1, the TXA group reported a VAS pain score of 2.5 ± 0.7, compared with 4.8 ± 1.0 in the control group (P < 0.001). This difference in pain levels persisted at day 15 (TXA: 1.3 ± 0.5 vs. control: 2.4 ± 1.1, P < 0.001), and the pain levels were similar between the groups at week 6 (TXA: 0.8 ± 0.7 vs. control: 1.8 ± 0.7, P = 0.028) (Fig. 2B).
3.4 Quadriceps strength and ROM
Quadriceps strength was better in the TXA than in the control group (Table 4), with differences observed at day 1 (TXA: 2.7 ± 0.5 vs. control: 2.4 ± 0.6, P = 0.043) and day 15 (TXA: 3.9 ± 0.5 vs. control: 3.3 ± 0.9, P = 0.009) (Fig. 2C). The postoperative ROM of the TXA group was better than that of the control group (TXA: 74.8 ± 3.6 vs. control: 69.4 ± 5.0, P < 0.001). ROM measurements were significantly more improved in the TXA group at week 6 (TXA: 100.0 ± 5.3 vs. control: 96.2 ± 5.5, P = 0.030), and this trend continued at week 12 (TXA: 110.1 ± 4.7 vs. control: 105.3 ± 4.9, P < 0.010) (Fig. 2D).
3.5 Incidence of fever and other complications
The incidence rate of postoperative fever was low in both groups, with no marked difference observed between the TXA and control groups at any time point (Table 4). No complications, such as deep vein thrombosis or infection, were reported in either group during the follow-up period.
4 Discussion
This study highlighted the important role of TXA in improving early recovery outcomes in patients undergoing double-bundle ACLR. TXA was shown to effectively reduce postoperative haemarthrosis and contribute to better pain management, enhanced quadriceps strength, and improved ROM during the early postoperative period. These outcomes are particularly important, given the increased complexity and associated risks of the double-bundle ACLR technique.
Double-bundle ACLR is increasingly recognised for its superior ability to restore the natural biomechanics of the knee, particularly in terms of rotational stability.9,16 However, this enhanced biomechanical replication comes at the cost of increased surgical trauma, including the need for multiple grafts and additional drilling, which can lead to greater intraoperative bleeding and a higher incidence of postoperative haemarthrosis.7,16 By inhibiting the excessive activity of the fibrinolytic system, TXA helps maintain the balance of the haemostatic system, allowing postoperative blood clots to more effectively prevent blood leakage into the surrounding tissues. It plays an important role in reducing postoperative haematoma formation, swelling, and inflammatory responses. In this study, TXA administration was associated with a substantial reduction in postoperative haemarthrosis, as evidenced by the lower CY scores on postoperative days 1 and 15. This aligns with the findings of previous orthopaedic studies, where TXA was proven to reduce both intraoperative and postoperative bleeding across various procedures, including total knee arthroplasty and hip arthroplasty.2,12,13 TXA effectively reduces joint effusion and inflammation.7,17
In addition to its role in reducing haemarthrosis, TXA has a direct effect on postoperative pain management and functional recovery. Pain and joint swelling are closely associated with the volume of haemarthrosis. Thus, by minimising joint effusion, TXA helps alleviate pain and promotes faster recovery. Patients in the TXA group reported substantially lower VAS pain scores on days 1 and 15 and week 6 compared to the control group. This reduction in pain is consistent with the findings of Chiang et al. who observed decreased joint effusion and pain after ACLR with TXA administration.11 However, our study demonstrated more pronounced early pain relief, compared with previous studies, such as that by Felli et al. where the differences in pain relief were less substantial.5 This discrepancy may be due to a higher baseline risk of bleeding in double-bundle ACLR, which makes TXA more effective in controlling postoperative complications.
The early pain reduction facilitated by TXA administration also supports faster functional recovery, particularly in terms of quadriceps strength and ROM. On postoperative days 1 and 15, patients in the TXA group exhibited greater quadriceps strength than did those in the control group, which is consistent with the findings of Karaaslan et al. who also reported considerable improvements in early quadriceps function with TXA.13 Additionally, the current study found that TXA contributed to improved ROM at both 6 and 12 weeks postoperatively, suggesting that reduced joint effusion promotes early mobility and enhances overall rehabilitation outcomes.2 Frobell et al. emphasised the importance of reducing postoperative pain and effusion to prevent muscle atrophy and joint stiffness1; the current study suggests that TXA may accelerate the return to normal function, helping to minimise long-term complications.
The current results differ from those of other researchers regarding functional recovery timelines. For instance, Fried et al. found less pronounced effects of TXA on ROM at 6 weeks,18 whereas our study demonstrated marked improvements in ROM at 6 and 12 weeks. These differences may be attributed to variations in surgical techniques, rehabilitation protocols, or complexity of the double-bundle reconstruction procedure. Given the increased surgical trauma associated with double-bundle ACLR, TXA appears to play an essential role in optimising the recovery process by reducing haemarthrosis and allowing for earlier rehabilitation efforts. This aligns with a growing body of literature supporting the use of TXA in various orthopaedic procedures to mitigate the risk of postoperative bleeding and improve clinical outcomes.13 Moreover, the ability of TXA to reduce postoperative complications, such as fever and wound issues, further strengthens its role as a standard adjunct in ACLR.6,18
This study had some limitations. The retrospective design may have introduced a selection bias and limited causality. Further, the lack of long-term follow-up restricts our understanding of sustained outcomes, such as joint health and function. Additionally, being a single-centre study, the findings may not be generalisable to other settings. The outcome measures were limited, potentially overlooking other important aspects, such as patient-reported outcomes and quality of life. Potential observer bias, despite efforts to blind the assessors, may have influenced the subjective evaluations.
5 Conclusion
The use of TXA during double-bundle ACLR may reduce postoperative joint haemarthrosis and enhance short-term functional outcomes. Future research should explore long-term effects, optimal dosing, impacts on different patient groups, and comparisons with single-bundle surgeries.
CRediT authorship contribution statement
Li Cen: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft. Hua Liu: Conceptualization, Methodology, Writing – review & editing. Ming Li: Formal analysis, Investigation, Writing – review & editing. Yun-Feng Zhang: Formal analysis, Investigation, Writing – review & editing. Hao-Jun Zhang: Formal analysis, Investigation, Writing – review & editing. Zhe-Yu Huang: Conceptualization, Methodology, Writing – review & editing, Supervision, All authors have agreed to be held accountable for the content of the work.
Guardian patients consent
Written informed consent was obtained from all patients for the publication of any potentially identifiable images or data included in this article.
Ethics approval and consent to participate
The studies involving human participants were reviewed and approved by Ningbo No. 6 Hospital Ethics Committee (No. 2024–77). Written informed consent was obtained from all patients for the publication of any potentially identifiable images or data included in this article.
Ethical statement
The studies involving human participants were reviewed and approved by Ningbo No. 6 Hospital Ethics Committee (No. 2024–77).
Use of generative AI and AI-assisted technologies in the writing process
No generative artificial intelligence (AI) and AI-assisted technologies in the writing process.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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