Blood Management in Total Knee Arthroplasty: Updates and Debates

major issue since it can result in hematoma, blood transfusion, periposthetic joint infection, delayed rehabilitation, and prolonged hospitalization as well as serious hemodynamic complications such as deep vein thrombosis and pulmonary embolism 1,2). The theme of this issue of the Knee Surgery & Related Research is blood management in TKA. The current issue contains four articles including one review article written by experts in blood management. Following the article that nicely summarizes recent updates, this issue presents three articles focusing on recently emerging but relatively controversial topics such as tranexamic acid (TXA) administration and various methods for postopera-tive drainage in order to generate the interest of the readers of the journal and the need for further related researches. It has been reported that the amount of blood loss after TKA ranges from 1,400 to 1,800 mL, and accordingly the frequency of blood transfusion can be as high as 40% 3,4). Therefore, various blood conservation strategies for reducing perioperative bleeding and transfusion have been attempted including hypotensive anesthesia, autologous blood transfusion, intraoperative cell saver, plugging of the femoral canal, cementing, drain clamping, navigation, minimally invasive surgery, pneumatic tourniquet application , and the use of TXA 3,5,6). However, it is almost unfeasible to select one or two best approaches. Thus, the recent trend is towards multimodal approaches efficiently incorporating various effective methods. The article by Liu et al. reviews the literature related to blood management strategies in the preoperative, intra-operative, and postoperative periods in TKA. The authors highlight the importance of preoperative hemoglobin optimization, minimal blood loss, and evidence-based guidelines. Moreover, it addresses an individualized, patient-specific multimodal approach and argues the " zero " allogenic postoperative transfusion rate should be the aim and an achievable goal of successful TKA procedures. TXA, an anti-fibrinolytic agent, is a plasminogen inhibitor that is widely recognized as easy to administer and efficient for reduction of blood loss in major surgical procedures including joint replacement surgeries. The efficacy and safety of TXA in reducing blood loss have been demonstrated in numerous level 1 studies and high quality meta-analyses 4,7). On the other hand, since TXA affects the fibrinolytic system, it carries the risk of throm-boembolic events 8,9). Postoperative venous thromboembolism is a potentially devastating complication of arthroplasties. Thus, due to the concern that the use of TXA may increase the risk of this serious complication, the efficacious agent for lowering post-operative bleeding and transfusion has been questioned …