• Danai Heebthamai Department of Orthopedics, Phramongkutklao College of Medicine, Bangkok, Thailand
  • Noppadol Aegakkatajit Orthopedic Unit, Buriram Hospital, Buriram, Thailand
  • Thanainit Chotanaphuti Department of Orthopedics, Phramongkutklao College of Medicine, Bangkok, Thailand
  • Saradej Khuangsirikul Department of Orthopedics, Phramongkutklao College of Medicine, Bangkok, Thailand



Total knee arthroplasty, Periarticular epinephrine injection, Hemoglobin recovery, Randomized-controlled trial


Background:  Anemia is one of the common complications occurring after total knee arthroplasty (TKA). A periarticular epinephrine injection could reduce intraoperative blood loss after TKA. However, the duration of hemoglobin recovery to preoperative level remains uncertain. The hypothesis was based on the concept that epinephrine affects vasoconstriction and reduces blood loss. This study was conducted to compare the duration of hemoglobin recovery to preoperative level between periarticular epinephrine injection and periarticular nonepinephrine injection groups and postoperative blood transfusion.

Methods: A total of 141 participants were randomized to receive a periarticular epinephrine and bupivacaine injection (epinephrine group) or periarticular bupivacaine injection (non-epinephrine group) among patients undergoing TKA. The solution consisted of 10 g of epinephrine 1 ml and 20 ml of 0.25% bupivacaine. In another group, the solution consisted of 20 ml of 0.25% bupivacaine alone.  All TKAs were managed under spinal anesthesia using a femoral nerve block. Preoperative and postoperative hemoglobin (Hb) and hematocrit (Hct) levels were assessed 1-day, 3-day and monthly until 6 months. Blood loss and the duration of Hb recovery to preoperative level were compared between the two groups.

Results: The percentage of Hb loss was slightly higher in the epinephrine group than that in the nonepinephrine group but without significance (13.4 ± 6.6% vs. 13.01 ± 5.01%; p=0.703). The duration of Hb recovery to preoperative level was about the same in the epinephrine and nonepinephrine groups (2.52 ± 1.080 months vs. 2.56 ± 1.089 months; p=0.855). The calculated total blood loss in the epinephrine group was lower than that in the nonepinephrine group (570 ± 302 mL vs. 573 ± 228 mL; p=0.955). In this study, surgery was performed without blood transfusions.

Conclusion: The duration of Hb recovery to preoperative level was 2.5 months which was about the same in both groups. Epinephrine injection did not decrease total blood volume loss after TKA under spinal anesthesia.   


Metrics Loading ...


Tsukada S, Wakui M, Hoshino A. Postoperative epidural analgesia compared with intraoperative periarticular injection for pain control following total knee arthroplasty under spinal anesthesia: a randomized controlled trial. J Bone Joint Surg Am 2014; 96: 1433-8. DOI:

Jasper LL, Jones CA, Mollins J, Pohar SL, Beaupre LA. Risk factors for revision of total knee arthroplasty: a scoping review. BMC Musculoskelet Disord 2016; 17: 182. DOI:

Anderson LA, Engel GM, Bruckner JD, Stoddard GJ, Peters CL. Reduced blood loss after total knee arthroplasty with local injection of bupivacaine and epinephrine. J Knee Surg 2009; 22: 130-6. DOI:

Kurosaka K, Tsukada S, Seino D, Morooka T, Nakayama H, Yoshiya S. Local infiltration analgesia versus continuous femoral nerve block in pain relief after total knee arthroplasty: A randomized controlled trial. J Arthroplasty 2016; 31: 913-7. DOI:

Fan L, Yu X, Zan P, Liu J, Ji T, Li G. Comparison of local iInfiltration analgesia with femoral nerve block for total knee arthroplasty: A prospective, randomized clinical trial. J Arthroplasty 2016; 31: 1361-5. DOI:

Nakagawa S, Arai Y, Inoue H, Kan H, Hino M, Ichimaru S, et al. Comparative effects of periarticular multimodal drug injection and single-shot femoral nerve block on pain following total knee arthroplasty and factors influencing their effectiveness. Knee Surg Relat Res 2016; 28: 233-8. DOI:

Lombardi AV, Jr., Berend KR, Mallory TH, Dodds KL, Adams JB. Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop Relat Res 2004: 125-30. DOI:

Lacher DA, Barletta J, Hughes JP. Biological variation of hematology tests based on the 1999-2002 National Health and Nutrition Examination Survey. Natl Health Stat Report 2012: 1-10.

Zhou Q, Zhou Y, Wu H, Wu Y, Qian Q, Zhao H, et al. Changes of hemoglobin and hematocrit in elderly patients receiving lower joint arthroplasty without allogeneic blood transfusion. Chin Med J (Engl) 2015; 128: 75-8. DOI:

Erskine JG, Fraser C, Simpson R, Protheroe K, Walker ID. Blood loss with knee joint replacement. J R Coll Surg Edinb 1981; 26: 295-7.

Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty.Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 2004; 86: 561-5. DOI:

Stucinskas J, Tarasevicius S, Cebatorius A, Robertsson O, Smailys A, Wingstrand H. Conventional drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis: a prospective, randomised trial. Int Orthop 2009; 33: 1275-8. DOI:

Wang D, Xu J, Zeng WN, Zhou K, Xie TH, Chen Z, et al. Closed suction drainage is not associated with faster recovery after total knee arthroplasty: A prospective randomized controlled study of 80 patients. Orthop Surg 2016; 8: 226-33. DOI:

Chotanaphuti T, Wangwittayakul V, Khuangsirikul S, Foojareonyos T. The accuracy of component alignment in custom cutting blocks compared with conventional total knee arthroplasty instrumentation: prospective control trial. Knee 2014; 21: 185-8. DOI:

Gibon E, Courpied JP, Hamadouche M. Total joint replacement and blood loss: what is the best equation? Int Orthop 2013; 37: 735-9. DOI:

Prasad N, Padmanabhan V, Mullaji A. Blood loss in total knee arthroplasty: an analysis of risk factors. Int Orthop 2007; 31: 39-44. DOI:

Gao F, Sun W, Guo W, Li Z., Wang W, Cheng L. Topical administration of tranexamic acid plus diluted-epinephrine in primary total knee arthroplasty: A randomized double-blinded controlled trial. J Arthro 2015; 30: 1354-8. DOI:

Holt BT, Parks NL, Engh GA, Lawrence JM. Comparison of closed-suction drainage and no drainage after primary total knee arthroplasty. Orthopedics 1997; 20: 1121-4; discussion 4-5. DOI:

Jenny JY, Boeri C, Lafare S. No drainage does not increase complication risk after total knee prosthesis implantation: a prospective, comparative, randomized study. Knee Surg Sports Traumatol Arthrosc 2001; 9: 299-301. DOI:




How to Cite

Heebthamai D, Aegakkatajit N, Chotanaphuti T, Khuangsirikul S. RECOVERY OF HEMOGLOBIN LEVEL FOLLOWING TOTAL KNEE ARTHROPLASTY WITH PERIARTICULAR EPINEPHRINE INJECTION. J Southeast Asian Med Res [Internet]. 2019 Jun. 18 [cited 2024 Apr. 17];3(1):32-9. Available from:



Original Articles

Most read articles by the same author(s)

Similar Articles

1 2 3 4 5 > >> 

You may also start an advanced similarity search for this article.