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Tranexamic acid for ankle arthroscopy patients with arthrofibrosis

Open AccessPublished:January 19, 2023DOI:https://doi.org/10.1016/j.fastrc.2023.100266

      Abstract

      Arthrofibrosis of the ankle can lead to severe stiffness and is difficult to manage despite repeated arthroscopic debridement. One of the causes which could lead to the formation of arthrofibrotic scar tissue is intraarticular bleeding. Tranexamic acid (TXA) is an antifibrinolytic agent which has been used successfully in the hip and knee to decrease intraarticular and postoperative bleeding. However, there is a paucity of literature on the potential benefits of TXA in ankle surgery, particularly ankle arthroscopy. We retrospectively studied all patients who received an intra-articular and intravenous injection of TXA during ankle arthroscopy between January 2019 and December 2020. The primary outcome measure was knee-to-wall distance. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire (MOXFQ); the American Orthopaedic Society Foot and Ankle Society Hindfoot Score (AOFAS) and a 9-item pain questionnaire which were collected preoperatively and at 6 months to 1 year postoperatively. The knee to wall distance improved significantly from a mean of 3.83 cm (SD±3.06 cm) preoperatively to 8.83 cm (SD,±4.26 cm). The AOFAS and MOXFQ scores improved significantly from a mean of 50.63 (SD,±21.58) and 35.38 (SD,±12.45) preoperatively to 81.50 (SD,±15.18) and 15.75 (SD,±12.20) respectively at postoperative follow-up. The pain scores also improved significantly from a median of 18 (range: 13–34) to 31 (range: 22–36). This study seems to show that intra-articular and intravenous injections of TXA are a potentially safe and effective technique to improve persistent pain and stiffness in the ankle in a difficult cohort of arthrofibrotic patients when assessed at short-term follow-up.

      Keywords

      Level of evidence

      Introduction

      Arthrofibrosis of the ankle is one of the unsolved dilemmas facing foot and ankle surgeons and traditionally, it has been very difficult to improve pain, stiffness and function in this cohort of patients.
      • Usher K.M.
      • Zhu S.
      • Mavropalias G.
      • et al.
      Pathological mechanisms and therapeutic outlooks for arthrofibrosis.
      The pathology is characterised by excessive scar tissue formation, leading to joint stiffness and soft tissue contractures. The pathophysiology of arthrofibrosis is incompletely understood, but it can occur secondary to trauma, infection or intraarticular bleeding. Several cytokines and growth factors contribute to this process.
      • Ibrahim IO
      • Nazarian A
      • Rodriguez EK.
      Clinical management of arthrofibrosis: state of the art and therapeutic outlook.
      • Vega J
      • Dalmau-Pastor M
      • Malagelada F
      • Fargues-Polo B
      • Peña F.
      Ankle arthroscopy: an update.
      • Benoni G
      • Fredin H.
      Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients.
      • Chen Antonia F.
      • Lee Yong Seuk
      • Seidl Adam J.
      • Abboud Joseph A
      Arthrofibrosis and large joint scarring.
      Ankle arthroscopy is a common procedure used to debride the anterior and less frequently posterior ankle joint of arthrofibrotic tissue including posteromedial impingement (POMI) lesions which lead to mechanical blockages against dorsiflexion and plantarflexion. Despite good to excellent outcomes, not all patients experience relief of symptoms.
      • Ibrahim IO
      • Nazarian A
      • Rodriguez EK.
      Clinical management of arthrofibrosis: state of the art and therapeutic outlook.
      ,
      • Vega J
      • Dalmau-Pastor M
      • Malagelada F
      • Fargues-Polo B
      • Peña F.
      Ankle arthroscopy: an update.
      One of the adjuncts that has recently been discussed in the literature is TXA. It has been studied and implemented widely since its physiological properties were discovered a few decades ago: inhibiting fibrinolysis by blocking the lysine-binding sites of plasminogen to fibrin. Some of its earliest applications were in general urological, gynaecological and thoracic surgery, where it would reduce intraoperative blood loss.
      • Benoni G
      • Fredin H.
      Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients.
      Recently, attention has turned towards the use of TXA in orthopaedic surgery, with an increasing number of studies showing the efficacy of TXA in surgeries of both large and small joints. Many randomised controlled trials have demonstrated reduced perioperative blood loss and transfusion rates when TXA is used in both total hip and total knee arthroplasties.
      • Charoencholvanich K.
      • Siriwattanasakul P.
      Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial.
      • Gomez-Barrena E
      • Ortega-Andreu M
      • Padilla-Eguiluz NG
      • Pérez-Chrzanowska H
      • Figueredo-Zalve R.
      Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial.
      • Sun Q
      • Yu X
      • Wu J
      • Ge W
      • Cai M
      • Li S.
      Efficacy of a single dose and an additional dose of tranexamic acid in reduction of blood loss in total knee arthroplasty.
      • Wu Q.
      • Zhang HA.
      • Liu SL.
      • et al.
      Is tranexamic acid clinically effective and safe to prevent blood loss in total knee arthroplasty? A meta-analysis of 34 randomized controlled trials.
      • Yang ZG
      • Chen WP
      • Wu LD.
      Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis.
      • Fillingham YA
      • Ramkumar DB
      • Jevsevar DS
      • Yates AJ
      • Shores P
      • Mullen K
      • Bini SA
      • Clarke HD
      • Schemitsch E
      • Johnson RL
      • Memtsoudis SG
      • Sayeed SA
      • Sah AP
      • Della Valle CJ
      The efficacy of tranexamic acid in total hip arthroplasty: a network meta-analysis.
      • Moskal JT
      • Capps SG.
      Meta-analysis of intravenous tranexamic acid in primary total hip arthroplasty.
      • Sukeik M
      • Alshryda S
      • Haddad FS
      • Mason JM.
      Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement.
      By decreasing bleeding, we think that TXA could decrease the formation of scar tissue and hence stiffness.
      However, there has been a paucity of literature studying the use of TXA in foot and ankle surgery. There have been some studies investigating blood loss in total ankle arthroplasty and calcaneal fractures, however very few that assessed the role of TXA in ankle arthrofibrosis.
      • Johns WL
      • Walley KC
      • Jackson 3rd, B
      • Gonzalez TA.
      Tranexamic acid in foot and ankle surgery: a topical review and value analysis.
      • Nodzo SR
      • Pavlesen S
      • Ritter C
      • Boyle KK.
      Tranexamic acid reduces perioperative blood loss and hemarthrosis in total ankle arthroplasty.
      • Steinmetz R.Garrett
      • Luick Laura
      • Tkach Shaun
      • Falcon Spencer
      • Stoner Julie
      • Hollabaugh Kimberly
      • Ringus Vytautas
      • Haleem Amgad M
      Effect of tranexamic acid on wound complications and blood loss in total ankle arthroplasty.
      • Xie Bing
      • Tian Jing
      • Zhou Da-peng
      Administration of tranexamic acid reduces postoperative blood loss in calcaneal fractures: a randomized controlled trial.
      The purpose of this study was to retrospectively review patients who underwent arthroscopy and received TXA intraoperatively. The primary outcomes included postoperative pain, stiffness, and function in the short term. Our other goal was to ascertain the safety of TXA in such surgeries. Given the results of previous studies, our hypothesis for this study was that the use of TXA intraoperatively would reduce intraarticular bleeding and hence reduce postoperative pain and stiffness.

      Patients and Methods

      This study included patients who were administered intravenous and intraarticular TXA during ankle arthroscopy. TXA was administered if patients were observed to have excessive intra-articular bleeding on the table while the tourniquet was inflated and were at high risk of developing arthrofibrosis or had previous arthrofibrosis diagnosed during foot and ankle surgery. Patients were excluded if they were younger than 18 years. The current report includes all eligible patients treated between January 2019 and December 2020, providing a follow-up duration of 6 months to 1 year.
      This study was approved by the local medical ethics committee. All patients provided verbal consent before participation in this study.

      Operative Technique

      All procedures were performed by the senior author (O.W.) using a standard arthroscopic technique. In brief, a thigh tourniquet was inflated prior to surgery. Anterior ankle arthroscopy was performed via standard anterolateral and anteromedial portals. Posterior arthroscopy was performed via standard posteromedial and posterolateral portals.
      Any observed bony impingement lesions were removed with an ostectomy, and any osteochondral defects were debrided and drilled to healthy bleeding bone using a microfracture technique. Any observed synovitis and arthrofibrosis was debrided using a shaver. If during ankle arthroscopy it was noted that the patient had excessive intra-articular bleeding on the table, 10ml of 100mg/ml IV TXA was administered on the table while the tourniquet was inflated. Then, an additional 10ml of 100mg/ml TXA was injected intraarticularly once the portals were closed, just prior to the tourniquet being released.
      Postoperatively, patients wore compression bandages for 3 days. They were allowed to weight bear as tolerated with or without crutches. They underwent gentle physiotherapy over the following weeks with the hospital physiotherapist. Early mobilisation of the ankle was encouraged. Compression stockings were worn up to the wound review at 2 weeks postoperatively. Further regular physiotherapy was continued thereafter.

      Outcome Assessment

      Patients were assessed at 6 months to 1 year postoperatively. Results were collected by the sole research assistant (M.S.) independent of the surgeon. Preoperatively, either CT or MRI was obtained of all affected ankles to assess any local orthopaedic pathology. The primary outcome measure was ankle stiffness and range of motion which was measured preoperatively and postoperatively by the knee to wall distance. This was measured by having the patient lunging forward until their knee contacted a wall, and while the heel was still in contact with the ground, measured the distance from the most anterior part of the foot to the wall in centimetres. If the knee was unable to contact the wall, then the anterior part of the foot was placed against the wall and the distance from the wall to the knee was measured in negative centimetres.
      Secondary outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale,
      • Kitaoka HB
      • Alexander IJ
      • Adelaar RS
      • Nunley JA
      • Myerson MS
      • Sanders M.
      Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes.
      Manchester-Oxford Questionnaire (MOXFQ) score
      • Morley D
      • Jenkinson C
      • Doll H
      • Lavis G
      • Sharp R
      • Cooke P
      • Dawson J.
      The Manchester-Oxford Foot Questionnaire (MOXFQ): Development and validation of a summary index score.
      as well as a 36-point pain score.
      Established in 1994, the AOFAS Ankle Hindfoot Scale has subjective and objective components and outputs a score with a maximum of 100 points.
      • Kitaoka HB
      • Alexander IJ
      • Adelaar RS
      • Nunley JA
      • Myerson MS
      • Sanders M.
      Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes.
      Of the 100 points, 40 are assigned to pain, 50 to function and 10 to alignment. This score was completed after a patient interview and physical examination of the ankle preoperatively and postoperatively.
      The MOXFQ is a validated 16-item questionnaire that assesses 3 domains: pain, walking/standing and social interaction.
      • Morley D
      • Jenkinson C
      • Doll H
      • Lavis G
      • Sharp R
      • Cooke P
      • Dawson J.
      The Manchester-Oxford Foot Questionnaire (MOXFQ): Development and validation of a summary index score.
      Each of the 16 questions in this patient reported outcome is assessed using a 5-point scale that ranges from 0 (least severity) to 4 (most severe).
      The pain score assesses pain in the foot and ankle with 9 questions, each with a numerical score ranging from 0 (most severe) to 4 (least severe).

      Statistical Analysis

      Statistical analyses were performed by utilisation of SPSS software v27 (SPSS Inc). Categorical data is presented as frequency. Continuous data is described using mean with standard deviation or median with range depending on the distribution. As most of the data followed a skewed distribution, confirmed by observation, the Wilcoxon signed rank test was used to compare the preoperative and postoperative scores. Follow up was performed at 6 months to 1 year and the last available assessment was included in the analysis. A P value less than 0.05 was considered significant.

      Results

      A total of 9 patients underwent ankle arthroscopy with adjunctive TXA between January 2019 and December 2020. 1 patient was not able to complete the follow up questionnaire. 3 patients were not able to complete the knee to wall assessment at home due to independent factors or in the presence of the research assistant due to the COVID pandemic. The missing data was excluded from the statistical analysis.
      This cohort included 5 (56%) males and 4 (44%) females. The mean age was 36 (SD, ±11 years) and the follow up period was 6 months to 1 year.
      3 patients (33%) had undergone 2 prior surgeries, while 3 (33%) had had 1 prior operation. The remaining 3 patients (33%) had never had any prior surgical interventions. Anterior arthroscopies were by far the more common procedure with 8 out of the 9 patients (89%) receiving that intervention. 3 of the 9 patients (33%) had a posterior arthroscopy and 2 had both (22%). 8 out of the 9 patients underwent ostectomies during arthroscopy.

      Knee to Wall distance

      The knee to wall distance improved significantly from a mean of 3.83 cm (SD, ±3.06 cm) before the procedure to 8.83 cm (SD, ±4.26 cm) (P = 0.027) at latest follow-up. 3 patients were either unable to recall their prior knee to wall distance or did not have the equipment to perform it at initial assessment.

      Reoperation rate and Complications

      No reoperations have been performed on any of the patients. No complications related to the treatments were reported by any of the patients, including no adverse reactions to TXA and no venous thromboembolic, infection or hemarthrosis related complications. No patients reported increased stiffness at latest follow-up.

      Functional Outcome

      AOFAS pain score improved from 20.00 (SD, ±9.26) preoperatively to 30.00 (SD, ±7.56) at follow up (P=0.023). AOFAS function score also improved significantly from 24.38 (SD, ±16.21) preoperatively to 42.75 (SD, ±6.98) postoperatively (P=0.012). The AOFAS alignment score also improved from 6.25 (SD, ±4.43) preoperatively to 8.75 (SD, ±2.31) at follow up. Overall, the AOFAS score improved significantly from 50.63 (SD, ±21.58) preoperatively to 81.50 (SD, ±15.18) at final follow up (P=0.012).
      The mean MOXFQ scores in the pain domain improved significantly from 11.00 (SD, ±4.31) preoperatively to 5.25 (SD, ±3.73) postoperatively (P=0.012). Significant improvement in the mean scores for the walking/standing and social interactions domain were also observed. The mean scores in the walking/standing domain decreased from 15.38 (SD, ±6.99) preoperatively to 6.38 (SD, ±5.83) and the mean scores in the social interaction domain decreased from 9.00 (SD, ±3.46) preoperatively to 4.13 (SD, ±3.94) postoperatively. Overall, the scores showed a significant mean improvement from 35.38 (SD, ±12.45) preoperatively to 15.75 (SD, ± 12.20) at postoperative follow-up (P=0.012).
      A 9-item questionnaire assessing pain also showed a significant improvement from a median of 18 (range: 13 – 34) to 31 (range: 22 – 36) (P = 0.018).

      Discussion

      Treatment and prevention of arthrofibrosis using TXA is a relatively new procedure, and there is a paucity of literature on this topic. In this current study, we have found significant improvement across all outcome measures. This demonstrates that it is potentially also more effective than arthroscopy alone in the short term. This retrospective study could provide the springboard for further investigation into the benefits of TXA in not only arthroscopic foot and ankle procedures, but other surgeries as well.
      The knee to wall test can be used as a measure of dorsiflexion and ankle stiffness.
      • Konor M.M.
      • Morton S.
      • Eckerson J.M.
      • Grindstaff T.L.
      Reliability of three measures of ankle dorsiflexion range of motion.
      This distance increased positively post treatment for all patients. Since ankle arthroscopy as a primary operation involves the removal of impingement lesions and debridement of arthrofibrotic tissue, this would also contribute to the outcome. However, in the patient cohort who have had multiple reoperations without resolution of symptoms or have had recurrence of arthrofibrosis, TXA does appear to at least be safe and not lead to a worsening of range of motion; and at best lead to an improvement in stiffness and range of motion, especially dorsiflexion in the ankle. In particular, for patient 1 PA, they had stiffness symptoms and reduced range of movement (ROM) for years and had failed 2 previous anterior arthroscopies before this treatment with TXA. Notably, this patient did not have any ostectomies performed during their operation. Their postoperative scores improved significantly across all outcome measures, including a knee to wall distance that increased remarkably from 5cm preoperatively to 12cm postoperatively. This case could potentially point towards the efficacy of TXA in reducing recurrence of stiffness in the ankle in the short to intermediate term.
      The AOFAS scores for all the patients improved postoperatively across all domains. The component with the greatest improvement was the function score, and the alignment score showed the least significant increase. A possible reason why this may have occurred is that most of the patients had a well aligned midfoot on physical examination during initial assessment, so there was minimal room for improvement due to a floor effect. However, the improvement in function is notable, especially given that some of these patients had had limited benefit from previous therapies. This potentially indicates that the use of TXA as an adjunct to arthroscopic treatment may prevent the development of arthrofibrosis in the short term. This is corroborated in the MOXFQ scores which showed a significant reduction in scores across all domains.
      Interestingly, 3 patients scored 0 (the best possible score) in 1 or more domains in the MOXFQ, with 2 patients scoring 0 or 1 overall. The same 2 patients also reported scores of 100 in their AOFAS questionnaire. While this could be an outlier result, it also suggests high levels of patient satisfaction with this treatment.
      Despite significant differences between preoperative and postoperative scores in most assessment scores, many of the patients still had symptoms. A significant change in outcome measure does not always correspond with clinically relevant differences in patient complaints. However, both the AOFAS and MOXFQ scores demonstrated statistically significant changes and a difference that was clinically relevant.
      • Dawson J
      • Doll H
      • Coffey J
      • Jenkinson C
      Oxford and Birmingham Foot and Ankle Clinical Research Group
      Responsiveness and minimally important change for the Manchester-Oxford foot questionnaire (MOXFQ) compared with AOFAS and SF-36 assessments following surgery for hallux valgus.
      Currently, the optimal treatment and prevention strategies for arthrofibrosis have not yet been identified.
      • Ibrahim IO
      • Nazarian A
      • Rodriguez EK.
      Clinical management of arthrofibrosis: state of the art and therapeutic outlook.
      While some of the risk factors that contribute to its occurrence are known, its management continues to present challenges to surgeons today. Arthroscopy is a commonly used procedure in both the diagnosis and treatment of foot and ankle conditions, including arthrofibrosis. While this procedure is considered to be relatively safe with few complications, some patients might experience postoperative hemarthrosis, which could contribute to the formation of scar tissue and further arthrofibrosis.
      • Usher K.M.
      • Zhu S.
      • Mavropalias G.
      • et al.
      Pathological mechanisms and therapeutic outlooks for arthrofibrosis.
      In hip, knee and shoulder procedures, TXA has already been shown to be effective in reducing postoperative bleeding.
      • Charoencholvanich K.
      • Siriwattanasakul P.
      Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial.
      • Gomez-Barrena E
      • Ortega-Andreu M
      • Padilla-Eguiluz NG
      • Pérez-Chrzanowska H
      • Figueredo-Zalve R.
      Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial.
      • Sun Q
      • Yu X
      • Wu J
      • Ge W
      • Cai M
      • Li S.
      Efficacy of a single dose and an additional dose of tranexamic acid in reduction of blood loss in total knee arthroplasty.
      • Wu Q.
      • Zhang HA.
      • Liu SL.
      • et al.
      Is tranexamic acid clinically effective and safe to prevent blood loss in total knee arthroplasty? A meta-analysis of 34 randomized controlled trials.
      • Yang ZG
      • Chen WP
      • Wu LD.
      Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis.
      • Fillingham YA
      • Ramkumar DB
      • Jevsevar DS
      • Yates AJ
      • Shores P
      • Mullen K
      • Bini SA
      • Clarke HD
      • Schemitsch E
      • Johnson RL
      • Memtsoudis SG
      • Sayeed SA
      • Sah AP
      • Della Valle CJ
      The efficacy of tranexamic acid in total hip arthroplasty: a network meta-analysis.
      • Moskal JT
      • Capps SG.
      Meta-analysis of intravenous tranexamic acid in primary total hip arthroplasty.
      • Sukeik M
      • Alshryda S
      • Haddad FS
      • Mason JM.
      Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement.
      More specifically, it can be effective in improving outcomes and reducing hemarthrosis-related complications in arthroscopic procedures of the knee, hip and shoulder. Importantly, no increase in complication rates have been reported following administration of TXA in these procedures, in particular no increase in venous thromboembolism (VTE)-related complications.
      • Belk JW
      • McCarty EC
      • Houck DA
      • Dragoo JL
      • Savoie FH
      • Thon SG.
      Tranexamic acid use in knee and shoulder arthroscopy leads to improved outcomes and fewer hemarthrosis-related complications: a systematic review of level I and II studies.
      • Karaaslan F
      • Karaoğlu S
      • Yurdakul E.
      Reducing intra-articular hemarthrosis after arthroscopic anterior cruciate ligament reconstruction by the administration of intravenous tranexamic acid: a prospective, randomized controlled trial.
      • Felli L
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      • Burastero G
      • Gatto P
      • Carletti A
      • Formica M
      • Alessio-Mazzola M
      Single intravenous administration of tranexamic acid in anterior cruciate ligament reconstruction to reduce postoperative hemarthrosis and increase functional outcomes in the early phase of postoperative rehabilitation: a randomized controlled trial.
      • Chiang ER
      • Chen KH
      • Wang ST
      • Ma HL
      • Chang MC
      • Liu CL
      • Chen TH.
      Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: a prospective randomized study.
      • Nugent M.
      • May J.H.
      • Parker J.D.
      • Kieser D.C.
      • Douglas M.
      • Pereira R.
      • Lim K.S.
      • Hooper G.J.
      Does tranexamic acid reduce knee swelling and improve early function following arthroscopic meniscectomy? A double-blind randomized controlled trial.
      • Liu YF
      • Hong CK
      • Hsu KL
      • Kuan FC
      • Chen Y
      • Yeh ML
      • Su WR.
      Intravenous administration of tranexamic acid significantly improved clarity of the visual field in arthroscopic shoulder surgery. a prospective, double-blind, and randomized controlled trial.
      This is a theoretical risk, and some investigators have suggested that TXA activates the fibrinolytic pathway but not coagulation.
      • Ross J
      • Al-Shahi Salman R.
      The frequency of thrombotic events among adults given antifibrinolytic drugs for spontaneous bleeding: systematic review and meta-analysis of observational studies and randomized trials.
      ,
      • Ker K.
      • Edwards P.
      • Perel P.
      • Shakur H.
      • Roberts I.
      Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis.
      Zhang et al.’s level 2 study of 61 patients undergoing open arthrolysis for post traumatic elbow stiffness found that topical administration of TXA helped reduce tourniquet time, operative blood loss and postoperative hematoma drainage volume. They hypothesized that this would also reduce rates of recurrence of stiffness and improve elbow rotation and motion arc. However, they found no significant difference between two groups, which they proposed was due to the effective drainage of any residual hematoma.
      • Zhang B
      • Zhang W
      • Xu J
      • Ding J.
      Effect of topical tranexamic acid on post-traumatic elbow stiffness in patients treated with open arthrolysis: a prospective comparative study.
      In our study, the patients were observed to have significantly reduced bleeding on the table when TXA was administered. Although no patients required postoperative drains inserted, we believe that the significantly improved clinical outcomes, in particular reduced stiffness associated with the improved knee to wall distance, can be due in part to the reduced rates of postoperative hemarthrosis from TXA administration.
      The literature surrounding the safety and efficacy of TXA administration in foot and ankle procedures is scarce and contentious. Similar to the results of previous studies in the knee and shoulder, in our case series, we found no postoperative complications, including VTE, infection, or hemarthrosis-related complications. Furthermore, the significant improvement in assessment scores and clinically relevant changes is encouraging for the administration of TXA in ankle arthroscopy. Nodzo et al.’s
      • Nodzo SR
      • Pavlesen S
      • Ritter C
      • Boyle KK.
      Tranexamic acid reduces perioperative blood loss and hemarthrosis in total ankle arthroplasty.
      retrospective review found decreased postoperative hemarthrosis in patients undergoing total ankle arthroplasty as well as a decreased rate of postoperative wound complications. This result is supported by Xie et al.’s
      • Xie Bing
      • Tian Jing
      • Zhou Da-peng
      Administration of tranexamic acid reduces postoperative blood loss in calcaneal fractures: a randomized controlled trial.
      randomised controlled trial involving 90 patients, which found a reduction in postoperative blood loss and wound complications in calcaneal fractures that were treated preoperatively with TXA. Additionally, they observed no obvious adverse effects or signs of thrombosis, which supports the safety of TXA in foot and ankle procedures. Despite these being major operations, this may suggest TXA could have similar benefits in arthroscopic foot and ankle procedures.
      In contrast to Nodzo et al, Steinmetz et al.
      • Steinmetz R.Garrett
      • Luick Laura
      • Tkach Shaun
      • Falcon Spencer
      • Stoner Julie
      • Hollabaugh Kimberly
      • Ringus Vytautas
      • Haleem Amgad M
      Effect of tranexamic acid on wound complications and blood loss in total ankle arthroplasty.
      discovered no significant difference in blood loss or wound complications between the total ankle arthroplasty patients who received TXA and the ones who did not in. However, they also found that the only patient in their study to have a pulmonary embolism as a complication was the one who did not receive TXA. This seems to imply that TXA is at least safe and non-inferior to treatment without it, and at best can improve postoperative outcomes and reduce risk of complications related to bleeding.
      An interesting area which needs further consideration is concurrent management of osteochondral defects (OCD) of the talar dome. A common treatment for small to intermediate sized OCD (<1.0cm2) is microfracturing.
      • Hannon CP
      • Bayer S
      • Murawski CD
      • Canata GL
      • Clanton TO
      • Haverkamp D
      • et al.
      Debridement, curettage, and bone marrow stimulation: proceedings of the international consensus meeting on cartilage repair of the ankle.
      The accepted mechanism of healing is from bleeding bone which evokes an inflammatory response, eventually leading to the formation of fibrocartilage.
      • Bryant 3rd, DD
      • Siegel MG.
      Osteochondritis dissecans of the talus: a new technique for arthroscopic drilling.
      The dilemma with TXA administration is that it may reduce all sources of bleeding within the joint, which may affect the healing of an OCD. To date there is no published literature examining this, and this should be an area of further investigation.
      Our study does have several limitations that need to be pointed out. Firstly, the small number of patients and limited follow up duration reduce the power of the study and only reflect results in the short to intermediate term. Secondly, the study is a retrospective review, which may allow for potential selection bias. Additionally, there was no reference group to compare the results to hence we are unable to prove that it is more effective than arthroscopy alone. Lastly, we acknowledge that this was a heterogeneous group of patients and most patients had ostectomies or other minor procedures performed during arthroscopy, which could have contributed to the reduced stiffness and improved outcomes.

      Conclusion

      In conclusion, our early results seem to suggest that TXA may reduce stiffness in ankle arthroscopies by reducing intraarticular bleeding and hence arthrofibrosis in a difficult cohort of patients. Early results are promising and seem to show that it can be associated with little to no complication rates and significant improvements in stiffness and function. To determine long-term outcomes concerning recurrence of symptoms and arthrofibrosis, more cases, a prospective study design and a longer follow-up period are required (Table 1).
      Table 1Summary of patients and their operation history.
      Age/Gender# Previous operationsNature of previous operationsAnterior/ Posterior arthroscopyOstectomy during arthroscopyOther procedures performed during arthroscopy
      Patient 1 PA51F21. L ankle scope and syndesmosis reconstruction

      2. L ankle scope and lateral and medial ligament reconstruction, peroneal debridement and repair
      AnteriorNo (N)
      Patient 2 TO50F0BothYes (Y)Removal of os trigonum
      Patient 3 CD28M21. lateral ligament reconstruction

      2. peroneal tenodesis
      Anterior



      Y
      Endoscopic gastrocnemius release
      Patient 4 AC27M21. posterior scope

      2. posterior scope
      Posterior

      YPeroneus brevis debridement

      Patient 5 JB32M0AnteriorY
      Patient 6 SM31M11. L anterior scope (ostectomy)AnteriorY
      Patient 7 AA49F11. L anterior scope (ostectomy tibia) syndesmosis reconstructionAnteriorY
      Patient 8 KC23F11. R anterior scope (ostectomy talus, tibia, lateral ligament reconstruction, peroneal debridement)BothY
      Patient 9 AM36M0AnteriorYMicrofracture for OCD

      Informed Patient Consent

      Complete verbal consent was obtained from the patients involved in this study and accompanying images.

      Declaration of interests

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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