# Perioperative Blood Loss in Cementless Versus Cemented Total Knee Arthroplasty With Local Tranexamic Acid Administration

## TL;DR

This study found that cementless and cemented knee replacements had similar blood loss when using a local-only tranexamic acid protocol.

## Contribution

The study demonstrates that a standardized local-only TXA protocol can achieve comparable blood loss in cementless versus cemented TKA.

## Key findings

- Cementless and cemented TKA had similar intraoperative and perioperative blood loss under a local-only TXA protocol.
- No transfusions were required in either group, and no symptomatic venous thromboembolism occurred.
- Cementless TKA had higher POD 7 D-dimer levels but no increased wound complications or infections requiring revision.

## Abstract

Background: Cementless total knee arthroplasty (TKA) has historically been associated with greater perioperative blood loss than cemented TKA. Whether a standardized local-only tranexamic acid (TXA) regimen can mitigate this difference remains unclear.

Objective: To compare perioperative blood loss between cementless and cemented TKA under a standardized local-only TXA protocol in a retrospective cohort, focusing on comparison rather than causation. Secondary outcomes included perioperative hemoglobin (Hb)/hematocrit (Hct) changes (preoperative to postoperative day (POD) 1), intraoperative and perioperative blood loss, transfusion, POD 7 D-dimer, operative time, and complications.

Methods: We retrospectively reviewed 103 consecutive unilateral primary TKAs performed at a single center (cementless, n=55; cemented, n=48) between 2013 and 2020. A standardized local TXA protocol was used in all cases (1 g periarticular before implantation and 1 g intra-articular before closure); no drains were used. Outcomes included operative time, perioperative Hb/Hct change, intraoperative blood loss, total perioperative blood loss estimated by the Gross formula, transfusion, complications, and POD 7 D-dimer. Group comparisons used t-tests with Welch’s correction or Mann-Whitney U tests, and Fisher’s exact tests for categorical variables.

Results: Baseline demographics were comparable between groups. Intraoperative blood loss was similar (cementless 91.4 ± 75.1 mL vs cemented 85.5 ± 111.2 mL; p=0.140), as was perioperative blood loss (154.3 ± 76.9 mL vs 132.9 ± 91.0 mL; p=0.204). No patient required transfusion. POD 7 D-dimer was higher in the cementless group (9.7±4.1 µg/mL vs 7.8±4.4 µg/mL; p=0.002), but no symptomatic venous thromboembolism occurred. Two late surgical-site infections in the cementless group resolved without revision or loosening; no wound complications occurred in either group.

Conclusions: Under a standardized local-only TXA protocol, cementless TKA achieved perioperative blood loss comparable to cemented TKA without increasing symptomatic thromboembolic events. These findings suggest the feasibility of a standardized local TXA protocol for cementless TKA. Importantly, fixation method was fully collinear with implant design (cementless: low contact stress (LCS) limited-box; cemented: posterior-stabilized (PS) open-box), and femoral box geometry can influence bleeding; therefore, results should be interpreted within this implant- and protocol-specific context.