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Surgical Haemostasis
Figure 1: Surgical Techniques for Total Knee Arthroplasty Figure 2: FloSeal Application
Traditional Mini-incision sub-vastus Quad-sparing™ incision
Minimally invasive surgical total knee arthroplasty
Traditional Mini-incision sub-vastus Quad-sparing™ incision
Minimally invasive surgical total knee arthroplasty
or after surgery, the best result that can be expected in the general, negative. They substantially increase the cost of surgery for a relatively
non-haemophilic population is that 70–80% of patients will not minor benefit. Therefore, we were interested in new options and started
require allogenic transfusion. Therefore, in normal circumstances, using a new topical haemostatic agent around one year ago. FloSeal
about 20–30% of cases will always need allogenic transfusion; this is Matrix is a combination of cross-linked gelatine granules and topical
the rate that needs to be reduced. Any new devices that can help human thrombin, which work together to promote haemostasis. The
reduce bleeding are welcome, particularly for use in inhibited granules swell on contact with moisture, meaning that they can conform
haemophilia patients. to irregular geometries and mechanically reduce the blood flow (see
Figure 2). Concurrently, blood flowing between the granules comes into
Haemostatic Agents contact with a high concentration of thrombin for optimal utilisation.
In Milan, as an adjunct to the above-mentioned techniques, we often Part of thrombin’s mechanism of action is to convert fibrinogen to fibrin
use fibrin glue/sealant or topical tranexamic acid. Many of the available monomers, which polymerise to form the clot. Similar to fibrin, thrombin
haemostasis agents that are made of cellulose, collagen and gelatine acts towards the end of the clotting cascade, which means it can be
work early on in the clotting cascade and rely on the patient’s fibrinogen used in patients with haemophilia. FloSeal is also resorbed as part of the
to provide the fibrin for clot formation. These agents are ineffective in normal wound-healing course.
13
patients with haemophilia. Fibrin sealant – essentially a mixture of
purified fibrinogen and thrombin – works late in the clotting cascade FloSeal has been used successfully in many different types of surgery,
and therefore is not affected by factor deficiencies or platelet including vascular surgery,
14,15
nephrectomy,
16,17
pituitary,
18
cardiac
19
malfunctions. It speeds up the formation of a stable clot and afterwards and spinal surgery.
20
It has been shown to be superior to competitor
is absorbed by the body during the normal healing process. It has been sealants, such as Gelfoam, particularly in controlling more severe
proved to reduce bloody drainage following TKA and to help maintain bleeding.
15,19
However, its utility in joint arthroplasty – particularly TKA
higher haemoglobin levels.
12
Working in a complementary fashion, in haemophilic patients – has not been thoroughly explored.
tranexamic acid prevents the conversion of plasminogen to plasmin and Therefore, we have initiated a prospective study on the efficacy of
thus inhibits the degradation of fibrin and promotes blood clotting. Both FloSeal on intra-operative bleeding in TKA in haemophilia patients.
these types of agents are safe and we have never experienced any
difficulties using them. One of the important considerations is determining the best time in
the operating procedure to use FloSeal. Given that immediately after
However, in our experience the cost–benefit ratio of these devices is application gentle pressure needs to be applied and there is a short
34 EUROPEAN MUSCULOSKELETAL REVIEW
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