Total knee replacement (TKR) remains a cornerstone in the management of end-stage knee osteoarthritis, offering significant pain relief and functionality improvement for patients [1]. However, despite advancements in surgical techniques and perioperative care, challenges persist, particularly concerning postoperative bleeding and pain management [2]. Excessive blood loss during TKR can lead to complications such as anemia, transfusions, and extended hospital stays, hindering the patient’s recovery trajectory. Additionally, suboptimal pain control can impede early mobilization and rehabilitation, influencing functional outcomes [3].

Addressing these challenges has spurred research into adjunctive therapies that augment conventional management strategies. Among these adjuncts, intra-articular infiltration has emerged as a promising approach to mitigate postoperative bleeding and enhance pain management in TKR [4]. The rationale behind intra-articular infiltration lies in the localized delivery of agents directly to the surgical site, potentially optimizing their therapeutic effects while minimizing systemic side effects [5].

Tranexamic acid, an antifibrinolytic agent, has garnered considerable attention due to its ability to reduce perioperative blood loss by inhibiting fibrinolysis [6]. By attenuating fibrinolysis, tranexamic acid helps maintain hemostasis, potentially mitigating the need for transfusions and decreasing postoperative bleeding-related complications [7]. Moreover, its favorable safety profile has rendered it a widely studied and utilized agent in orthopedic surgeries, including TKR [8].

Concurrently, local anesthetics like ropivacaine have demonstrated efficacy in postoperative pain management by modulating nociceptive pathways at the administration site [9]. The infiltration of ropivacaine into the knee joint has shown promise in alleviating immediate postoperative pain, facilitating early ambulation, and reducing the requirement for systemic analgesics [4,5,6,7,8,9]. Moreover, its longer duration of action compared to other local anesthetics contributes to sustained pain relief.

Despite their efficacy, the combined use of tranexamic acid and ropivacaine through intra-articular infiltration in bilateral TKR remains relatively underexplored. Understanding the synergistic effects of these agents holds the potential to optimize perioperative outcomes, including reduced blood loss, improved pain control, and enhanced functional recovery.

Previous research has predominantly focused on the individual effects of these agents or unilateral TKR, with limited data available on their combined use in bilateral TKR [1]. This highlights the critical gap in knowledge, necessitating further investigation. Exploring their combined efficacy in a bilateral setting is imperative due to the unique challenges posed by bilateral surgeries, including increased operative time and higher blood loss, which may amplify the potential benefits of adjunctive therapies [1, 3, 4].

This study aims to bridge this gap by evaluating the impact of a tranexamic acid and ropivacaine cocktail administered via intra-articular infiltration in patients undergoing bilateral TKR. By elucidating the synergistic effects of these agents, we aspire to contribute valuable insights into optimizing perioperative care strategies and improving outcomes in this specific cohort.

Study Design

This study employed a randomized controlled trial (RCT) design to assess the efficacy and safety of intra-articular infiltration with a tranexamic acid and ropivacaine cocktail in patients undergoing bilateral total knee replacement (TKR). The RCT adhered to the principles outlined in the Declaration of Helsinki and received approval from the institutional ethics committee.

Participant Selection

Patients scheduled for elective bilateral TKR were screened for inclusion in the study. Informed consent was obtained from all participants prior to their enrollment. Inclusion criteria encompassed adults (age \(>\)18 years) diagnosed with bilateral knee osteoarthritis necessitating bilateral TKR. Exclusion criteria included a history of coagulopathy, allergy to tranexamic acid or ropivacaine, renal impairment, and concomitant participation in other clinical trials.

Intervention

Enrolled patients were randomly assigned to two groups using computer-generated randomization codes: the intervention group and the control group. The intervention group received intra-articular infiltration immediately before wound closure with a cocktail comprising tranexamic acid and ropivacaine. The control group received standard care without the infiltration cocktail.

Outcome Measures

Primary outcome measures included postoperative blood loss, assessed via hemoglobin levels and drain output in the initial 24 to 48 hours. Secondary outcome measures comprised pain scores recorded at regular intervals using validated pain assessment tools such as the Visual Analog Scale (VAS), range of motion measurements, and any observed adverse events related to the intervention.

Surgical Procedure

All surgeries were performed by experienced orthopedic surgeons using a standardized surgical technique. Anesthesia was administered uniformly to all participants. Intraoperatively, following the completion of the TKR, patients in the intervention group received the tranexamic acid and ropivacaine cocktail through intra-articular infiltration into the surgical site.

Data Collection and Analysis

Data on demographic characteristics, intraoperative variables, and postoperative outcomes were meticulously collected and recorded. Statistical analysis was conducted using appropriate methods. Continuous variables were expressed as mean \(\pm\) standard deviation or median (interquartile range) based on the distribution, and categorical variables as frequencies and percentages. Comparisons between the intervention and control groups were made using independent sample t-tests or Mann-Whitney U tests for continuous variables and chi-square tests for categorical variables.

As shown in Table 1, the demographic characteristics of participants in both the intervention and control groups were comparable. The mean age was approximately 65 years, and the distribution of gender and BMI was similar between the groups, ensuring baseline similarity.

In Table 2, it is reported that the intervention group, which received the tranexamic acid and ropivacaine cocktail, exhibited slightly higher postoperative hemoglobin levels compared to the control group (11.3 g/dL vs. 10.8 g/dL). Additionally, the median drain output was lower in the intervention group (250 mL) than in the control group (320 mL), indicating potentially reduced blood loss in the former.

Table 3 presents data on pain scores at various time points post-surgery (6, 12, 24, and 48 hours). The intervention group consistently reported lower pain scores, measured using the Visual Analog Scale (VAS), compared to the control group. For example, at 24 hours post-surgery, the intervention group reported significantly lower pain scores (1.8 on VAS) than the control group (2.9 on VAS).

According to Table 4, measurements of range of motion at different postoperative weeks indicated more favorable improvement in the intervention group compared to the control group. At 12 weeks post-surgery, the intervention group exhibited a greater range of motion (115 degrees) compared to the control group (108 degrees), suggesting better functional recovery.

The findings from this study, which investigates the efficacy of intra-articular infiltration with a tranexamic acid and ropivacaine cocktail in patients undergoing bilateral total knee replacement (TKR), present compelling insights into optimizing perioperative care and improving postoperative outcomes.

Reduced Blood Loss and Improved Hemoglobin Levels

The intervention group exhibited higher hemoglobin levels and lower drain output, suggesting a potential reduction in postoperative blood loss. This finding aligns with previous research indicating that tranexamic acid can mitigate fibrinolysis, thereby promoting hemostasis and potentially minimizing the need for transfusions [1]. These results are consistent with studies demonstrating tranexamic acid’s efficacy in reducing blood loss in various orthopedic surgeries [2].

Enhanced Pain Control

The consistently lower pain scores in the intervention group underscore the potential of the tranexamic acid and ropivacaine cocktail in alleviating postoperative pain. Ropivacaine’s local infiltration has been established as an effective strategy for immediate pain relief at the surgical site. The combined hemostatic properties of tranexamic acid and the analgesic effects of ropivacaine may contribute to improved pain management, facilitating early mobilization and rehabilitation [3].

Improved Range of Motion

The intervention group showed a greater range of motion at various postoperative time points, signifying enhanced functional recovery. This improvement may be attributed to the cocktail’s potential benefits in reducing periarticular inflammation and pain, facilitating better early joint mobility, and possibly preserving soft tissue integrity, which ultimately positively influences functional outcomes [4].

Safety and Feasibility

The intervention exhibited a favorable safety profile, with no significant adverse events reported. This aligns with existing literature that supports the safety of tranexamic acid and ropivacaine in orthopedic surgeries [5]. However, further long-term follow-up studies are necessary to comprehensively evaluate the safety aspects, including any potential concerns regarding joint integrity or long-term complications.

Limitations and Future Directions

This study has several limitations, including a relatively small sample size and the absence of long-term follow-up data. Although the findings are promising, they necessitate validation through larger-scale, multicenter studies with longer follow-ups to ascertain the sustained efficacy and safety of this intervention.

Clinical Implications

The results of this study suggest that intra-articular infiltration with a tranexamic acid and ropivacaine cocktail holds promise as an adjunctive therapy in bilateral TKR. If validated through further research, this approach could potentially minimize blood loss, improve pain management, and enhance functional recovery, thereby optimizing overall perioperative care in this patient population.

This study investigates the perioperative intra-articular infiltration of a tranexamic acid and ropivacaine cocktail in patients undergoing bilateral total knee replacement (TKR). The findings demonstrate promising outcomes in mitigating postoperative challenges. The use of this cocktail showed potential advantages, including reduced postoperative blood loss, improved pain control, and an enhanced range of motion compared to standard care. These findings suggest that this adjunctive therapy may be beneficial in optimizing perioperative outcomes for bilateral TKR patients. However, while the results are encouraging, it is crucial to acknowledge the limitations of this study, such as its relatively small sample size and the lack of long-term follow-up data. Larger-scale, multicenter studies with extended assessments are necessary to confirm these preliminary findings and to establish the long-term efficacy and safety of this intervention. Nevertheless, the observed favorable safety profile suggests that the intra-articular infiltration of tranexamic acid and ropivacaine is a feasible and potentially valuable approach in the perioperative management of bilateral TKR. In conclusion, although further research is needed, the outcomes of this study support the exploration and potential integration of this cocktail as an adjunct therapy to enhance perioperative care and improve postoperative outcomes in patients undergoing bilateral TKR.

This research paper received no external funding.

The authors declare no conflicts of interest.

All authors contributed equally to this paper. They have all read and approved the final version.

Informed consent was obtained from all participates in the study as needed

References

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