1
|
Dragosloveanu S, Dragosloveanu C, Petre M, Gherghe ME, Cotor DC. The Impact of Tourniquet Usage on TKA Outcome: A Single-Center Prospective Trial. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050870. [PMID: 37241102 DOI: 10.3390/medicina59050870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/03/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Total knee arthroplasties (TKAs) are the most effective surgical treatment for end-stage knee osteoarthritis. The tourniquet is used to reduce intraoperative blood loss, improving surgical field visualization. There is much controversy regarding the effectiveness and safety of using a tourniquet during total knee arthroplasties. The purpose of this prospective study is to determine the effect of tourniquet usage during TKAs on early functional outcomes and pain in our center. Materials and Methods: We conducted a randomized controlled trial of patients following a primary total knee replacement between October 2020 and August 2021. We recorded presurgical data, which included age, sex and knee range of motion. Intraoperatively, we measured the amount of blood aspiration and the surgical room time. After the surgery, we measured the amount of blood aspirated through the drains and the hemoglobin. We measured flexion, extension, Visual Analogue Scale (VAS) scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC score) scores for the functional evaluation. Results: We included 96 patients in the T group and 94 in the NT group, respectively, who remained until the last follow-up. Regarding blood loss, the NT group demonstrated significantly lower levels: 245 ± 97.8 mL intraoperative and 324.8 ± 151.65 mL postoperative, compared to the T group, where we recorded 276 ± 109.2 mL during the surgical procedures and 353.44 ± 101.55 mL after the surgery, (p < 0.05). We also recorded significantly shorter operative room time for the NT group, (p < 0.05). During the follow-up, we noticed postoperative improvements but without significant differences between the groups. Conclusions: We found a significant decrease in bleeding after no tourniquet usage during total knee replacements and shorter operative times. On the other hand, the knee function demonstrated no significant differences between the groups. Further studies may be required in order to assess complications.
Collapse
Affiliation(s)
- Serban Dragosloveanu
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
- "Carol Davila" Faculty of Medicine, University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Christiana Dragosloveanu
- "Carol Davila" Faculty of Medicine, University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Clinical Hospital for Ophthalmological Emergencies, 030167 Bucharest, Romania
| | - Mihnea Petre
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
| | - Mihai E Gherghe
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
| | - Dragos C Cotor
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
| |
Collapse
|
2
|
Cao Q, Wu Q, Liu Y, He Z, Cong Y, Meng J, Zhao J, Bao N. Effects of Tourniquet Application on Faster Recovery after Surgery and Ischemia-Reperfusion Post-Total Knee Arthroplasty, Cementation through Closure versus Full-Course and Nontourniquet Group. J Knee Surg 2022; 35:1577-1586. [PMID: 33992032 DOI: 10.1055/s-0041-1728814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pneumatic tourniquets are used in total knee arthroplasty (TKA) for surgical field visualization and improved cementation; however, their use is controversial. This study aimed to assess the effects of tourniquet application on faster recovery post-TKA. Our hypothesis was that inflammation and limb function would be similar with different tourniquet applications. A prospective randomized double-blinded trial assessed tourniquets effects on postoperative pain, swelling, and early outcome in TKA. In present study, 50 TKAs were enrolled in each group as follows: full course (FC), cementation through closure (CTC), and no tourniquet (NT), CTC as treatment group while FC and NT as control groups. Topical blood samples of 3 mL from the joint cavity and drainage bags were obtained at special time point. At last, all samples such as tumor necrosis factor-a (TNF-a), C-C motif chemokine ligand 2 (CCL2), pentraxin 3 (PTX3), prostaglandin E2 (PGE2), superoxide dismutase 1 (SOD1), and myoglobin (Mb) were detected by ELISA. Active and passive range of motion (ROM) values, pain score by the visual analog scale (VAS), change of thigh circumference were recorded at special time point as well. In topical blood, the change of inflammatory factors, such as TNF-a, PTX3, CCL2, PGE2, SOD1, and Mb, was lower in CTC and NT groups than in FC group (p < 0.01 and 0.05). Although VAS and ROM were comparable preoperatively in three groups (p > 0.05), the perimeter growth rate was lower, pain scores (VAS) were reduced, and ROM values were improved in CTC and NT groups compared with FC group at T4, T5, and T6 postoperatively (p < 0.01 and 0.05). Improved therapeutic outcome was observed in the CTC group, indicating patients should routinely undergo TKA with cementation through closure tourniquet application.
Collapse
Affiliation(s)
- Qinggang Cao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Qiong Wu
- Department of Scientific Research and Training, Division of Health Service, General Hospital of Eastern theater of People's Liberation Army, Nanjing, Jiangsu, China
| | - Yun Liu
- Health Technology Cadre Training, Jingling Hospital, Nanjing, China
| | - Zhiwei He
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Yu Cong
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jia Meng
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jianning Zhao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China.,Health Technology Cadre Training, Jingling Hospital, Nanjing, China
| | - Nirong Bao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China.,Health Technology Cadre Training, Jingling Hospital, Nanjing, China
| |
Collapse
|
3
|
Ischemic preconditioning upregulates Mitofusin2 and preserves muscle strength in tourniquet-induced ischemia/reperfusion. J Orthop Translat 2022; 35:113-121. [PMID: 36312592 PMCID: PMC9582561 DOI: 10.1016/j.jot.2022.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Tourniquet-induced ischemia and reperfusion (I/R) has been related to postoperative muscle atrophy through mechanisms involving protein synthesis/breakdown, cellular metabolism, mitochondrial dysfunction, and apoptosis. Ischemic preconditioning (IPC) could protect skeletal muscle against I/R injury. This study aims to determine the underlying mechanisms of IPC and its effect on muscle strength after total knee arthroplasty (TKA). Methods Twenty-four TKA patients were randomized to receive either sham IPC or IPC (3 cycles of 5-min ischemia followed by 5-min reperfusion). Vastus medialis muscle biopsies were collected at 30 min after tourniquet (TQ) inflation and the onset of reperfusion. Western blot analysis was performed in muscle protein for 4-HNE, SOD2, TNF-ɑ, IL-6, p-Drp1ser616, Drp1, Mfn1, Mfn2, Opa1, PGC-1ɑ, ETC complex I-V, cytochrome c, cleaved caspase-3, and caspase-3. Clinical outcomes including isokinetic muscle strength and quality of life were evaluated pre- and postoperatively. Results IPC significantly increased Mfn2 (2.0 ± 0.2 vs 1.2 ± 0.1, p = 0.001) and Opa1 (2.9 ± 0.3 vs 1.9 ± 0.2, p = 0.005) proteins expression at the onset of reperfusion, compared to the ischemic phase. There were no differences in 4-HNE, SOD2, TNF-ɑ, IL-6, p-Drp1ser616/Drp1, Mfn1, PGC-1ɑ, ETC complex I-V, cytochrome c, and cleaved caspase-3/caspase-3 expression between the ischemic and reperfusion periods, or between the groups. Clinically, postoperative peak torque for knee extension significantly reduced in the sham IPC group (-16.6 [-29.5, -3.6] N.m, p = 0.020), while that in the IPC group was preserved (-4.7 [-25.3, 16.0] N.m, p = 0.617). Conclusion In TKA with TQ application, IPC preserved postoperative quadriceps strength and prevented TQ-induced I/R injury partly by enhancing mitochondrial fusion proteins in the skeletal muscle. The translational potential of this article Mitochondrial fusion is a potential underlying mechanism of IPC in preventing skeletal muscle I/R injury. IPC applied before TQ-induced I/R preserved postoperative quadriceps muscle strength after TKA.
Collapse
Key Words
- 4-HNE, 4-hydroxy-2-nonenal
- ADP, Adenosine diphosphate
- ASA, American Society of Anesthesiologists
- ATP, Adenosine triphosphate
- BSA, Bovine serum albumin
- CAT, Catalase
- CHOP, C/EBP homologous protein
- Drp1, Dynamin-related protein-1
- ER, Endoplasmic reticulum
- ETC, Electron transport chain
- FGF21, Fibroblast growth factor 21
- Fis1, Fission protein-1
- GPx, Glutathione peroxidase
- I/R, Ischemia and reperfusion
- IL-6, Interleukin-6
- IPACK, Interspace between the popliteal artery and capsule of the posterior knee
- IPC, Ischemic preconditioning
- Ischemia reperfusion injury
- Ischemic preconditioning
- Knee arthroplasty
- MDA, Malondialdehyde
- Mfn, Mitofusin
- Mitochondrial dynamics
- MnSOD, Manganese superoxide dismutase
- NF-κB, Nuclear factor kappa B
- OXPHOS, Oxidative phosphorylation
- PGC-1ɑ, Peroxisome proliferator-activated receptor-gamma coactivator-1ɑ
- RIPC, Remote ischemic preconditioning
- ROS, Reactive oxygen species
- SBP, Systolic blood pressure
- SOD, Superoxide dismutase
- TKA, Total knee arthroplasty
- TNF, Tumor necrosis factor
- TQ, Tourniquet
- Tourniquet
- UPR, Unfolded protein response
- mPTP, Mitochondrial permeability transition pore
Collapse
|
4
|
CoenzymeQ10 and Ischemic Preconditioning Potentially Prevent Tourniquet-Induced Ischemia/Reperfusion in Knee Arthroplasty, but Combined Pretreatment Possibly Neutralizes Their Beneficial Effects. Antioxidants (Basel) 2022; 11:antiox11020419. [PMID: 35204301 PMCID: PMC8869537 DOI: 10.3390/antiox11020419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 02/04/2023] Open
Abstract
Tourniquet (TQ) use during total knee arthroplasty (TKA) induces ischemia/reperfusion (I/R) injury, resulting in mitochondrial dysfunction. This study aims to determine the effects of coenzyme Q10 (CoQ10) and ischemic preconditioning (IPC), either alone or in combination, on I/R-induced mitochondrial respiration alteration in peripheral blood mononuclear cells (PBMCs) and pain following TKA. Forty-four patients were allocated into four groups: control, CoQ10, IPC, and CoQ10 + IPC. CoQ10 dose was 300 mg/day for 28 days. IPC protocol was three cycles of 5/5-min I/R time. Mitochondrial oxygen consumption rates (OCRs) of PBMCs were measured seven times, at baseline and during ischemic/reperfusion phases, with XFe 96 extracellular flux analyzer. Postoperative pain was assessed for 48 h. CoQ10 improved baseline mitochondrial uncoupling state; however, changes in OCRs during the early phase of I/R were not significantly different from the placebo. Compared to ischemic data, IPC transiently increased basal OCR and ATP production at 2 h after reperfusion. Clinically, CoQ10 significantly decreased pain scores and morphine requirements at 24 h. CoQ10 + IPC abolished analgesic effect of CoQ10 and mitochondrial protection of IPC. In TKA with TQ, IPC enhanced mitochondrial function by a transient increase in basal and ATP-linked respiration, and CoQ10 provides postoperative analgesic effect. Surprisingly, CoQ10 + IPC interferes with beneficial effects of each intervention.
Collapse
|
5
|
Cao Q, He Z, Fan Y, Meng J, Yuan T, Zhao J, Bao N. Effects of tourniquet application on enhanced recovery after surgery (ERAS) and ischemia-reperfusion post-total knee arthroplasty: Full- versus second half-course application. J Orthop Surg (Hong Kong) 2020; 28:2309499019896026. [PMID: 31965906 DOI: 10.1177/2309499019896026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Pneumatic tourniquets are used in total knee arthroplasty (TKA) for surgical field visualization and improved cementation; however, their use is controversial. This study aimed to assess the effects of tourniquet application on enhanced recovery post-TKA. METHODS A prospective randomized single-blinded trial assessed tourniquet's effects on postoperative pain, swelling, and early outcome in TKA. One-hundred and two patients with knee osteoarthritis were randomized to full-course (FC) and second half-course (SHC) application (n = 51/group). Tumor necrosis factor-alpha (TNF-α), C-C motif chemokine ligand 2(CCL-2), pentraxin-3 (PTX-3), prostaglandin E-2 (PGE-2), superoxide dismutase-1 (SOD-1), and myoglobin (Mb) were assessed by enzyme-linked immunosorbent assay, while the visual analog scale (VAS), range of motion (ROM), and thigh circumference growth rate were recorded. RESULTS Average tourniquet duration significantly differed between the SHC (37.5 ± 5.1 min) and FC (66.4 ± 7.2 min) groups (p < 0.01); VAS and thigh circumference growth rate in the SHC group were much lower compared with the FC group, while ROM was higher within 48 h of tourniquet removal (p < 0.01). Blood TNF-α, PTX3, CCL2, PGE2, SOD-1, and Mb were lower in the SHC group than the FC group (p < 0.01). Additionally, intraoperative blood loss was significantly elevated in the SHC group than the FC group (p < 0.01), with lower postoperative blood loss in the drain (p = 0.001). Postoperative drainage volume was reduced in the SHC group compared with the FC group (p < 0.01); five and two patients in the FC and SHC groups required blood transfusion, respectively (p = 0.025). Hospital stay tended to be shorter in the SHC group (p = 0.023), and no tourniquet-related complications were recorded. CONCLUSION Improved therapeutic outcome was observed in the SHC group, indicating patients should routinely undergo TKA with SHC tourniquet application.
Collapse
Affiliation(s)
- Qinggang Cao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Zhiwei He
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Yongfei Fan
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jia Meng
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Tao Yuan
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jianning Zhao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Nirong Bao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| |
Collapse
|
6
|
Chen H, Wei JQ, Wang YW, Zhou KP, He Y, Liu H, Zhang YY. Protective Effects of Rocuronium Bromide on Ischemia-Reperfusion Injury in Skeletal Muscle Induced by Tourniquet in Patients Undergoing Elective Unilateral Total Knee Arthroplasty: A Prospective, Double Blind, Randomized, Controlled Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:3373-3384. [PMID: 32884241 PMCID: PMC7443440 DOI: 10.2147/dddt.s252546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Purpose To investigate the effects of different doses of rocuronium on ischemia-reperfusion injury in skeletal muscle induced by tourniquet in patients undergoing elective unilateral total knee arthroplasty. Patients and Methods A total of 90 patients undergoing elective unilateral knee arthroplasty under general anesthesia combined with femoral nerve block were randomly divided into 3 groups: normal saline group (group S), rocuronium 0.6 mg/kg group (group L), and rocuronium 1.2 mg/kg group (group H). The primary outcome was the expression of dystrophin in skeletal muscle at 60 min after ischemia. Secondary outcomes included the concentration of malondialdehyde (MDA) and neuronal nitric oxide synthase (nNOS) in blood at 5 min and 30 min after reperfusion. In addition, thigh girth at 24 h and 48 h after operation, the leaving bed time, the incidence of tourniquet-related hypertension and short-term (3 days after operation) complications (nausea and vomiting, swelling, blister, wound infection) and long-term (3 months after operation) complications (joint instability, stiffness, nerve paralysis, pain) were recorded. Main Results The expression of dystrophin in the rocuronium group was higher than that in group S after ischemia (P <0.05). The concentration of MDA in the rocuronium 1.2 mg/kg group was lower at 30 min after reperfusion (P < 0.05). There was no significant difference in nNOS among groups at each time point (P > 0.05). The change of thigh girth was the smallest in the rocuronium 1.2 mg/kg group after operation (P<0.05). The leaving bed time was significantly earlier after operation in the rocuronium group than that in group S (P <0.05). Conclusion Rocuronium can protect skeletal muscle from ischemia-reperfusion injury induced by tourniquet. The mechanism may be related to the fact that rocuronium can reduce the loss of dystrophin in skeletal muscle and have the effects of anti-oxidation and anti-stress. Trial Registration The study was registered at http://www.chictr.org.cn (ChiCTR1800019221, registered on 2018-10-31).
Collapse
Affiliation(s)
- Hui Chen
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Jing-Qiu Wei
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Yi-Wen Wang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Kun-Peng Zhou
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Ying He
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - He Liu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Yue-Ying Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| |
Collapse
|
7
|
Duan C, Kuang L, Xiang X, Zhang J, Zhu Y, Wu Y, Yan Q, Liu L, Li T. Drp1 regulates mitochondrial dysfunction and dysregulated metabolism in ischemic injury via Clec16a-, BAX-, and GSH- pathways. Cell Death Dis 2020; 11:251. [PMID: 32312970 PMCID: PMC7170874 DOI: 10.1038/s41419-020-2461-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/31/2022]
Abstract
The adaptation of mitochondrial homeostasis to ischemic injury is not fully understood. Here, we studied the role of dynamin-related protein 1 (Drp1) in this process. We found that mitochondrial morphology was altered in the early stage of ischemic injury while mitochondrial dysfunction occurred in the late stage of ischemia. Drp1 appeared to inhibit mitophagy by upregulating mito-Clec16a, which suppressed mito-Parkin recruitment and subsequently impaired the formation of autophagosomes in vascular tissues after ischemic injury. Moreover, ischemia-induced Drp1 activation enhanced apoptosis through inducing mitochondrial translocation of BAX and thereby increasing release of Cytochrome C to activate caspase-3/-9 signalling. Furthermore, Drp1 mediated metabolic disorders and inhibited the levels of mitochondrial glutathione to impair free radical scavenging, leading to further increases in ROS and the exacerbation of mitochondrial dysfunction after ischemic injury. Together, our data suggest a critical role for Drp1 in ischemic injury.
Collapse
Affiliation(s)
- Chenyang Duan
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China
| | - Lei Kuang
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China
| | - Xinming Xiang
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China
| | - Jie Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China
| | - Yu Zhu
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China
| | - Yue Wu
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China
| | - Qingguang Yan
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China
| | - Liangming Liu
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China.
| | - Tao Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, P. R. China.
| |
Collapse
|
8
|
Jawhar A, Skeirek D, Stetzelberger V, Kollowa K, Obertacke U. No effect of tourniquet in primary total knee arthroplasty on muscle strength, functional outcome, patient satisfaction and health status: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2020; 28:1045-1054. [PMID: 31372679 DOI: 10.1007/s00167-019-05646-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/23/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Tourniquet use during primary total knee arthroplasty (TKA) may negatively impact the early postoperative functional recovery due to molecular effects of ischaemia. The hypothesis of the present study was that primary TKA without a tourniquet positively influences the postoperative muscle strength, functional outcome, patient satisfaction and health status. METHODS The monocentric, randomized, controlled trial included a total of 99 patients scheduled to undergo primary TKA (ClinicalTrials.gov NCT02475603). The patients were randomly assigned to the tourniquet (n = 50) or non-tourniquet (n = 49) group after receiving a written informed consent. As primary outcome parameter, the functional outcome, patient expectation/satisfaction and the health status were assessed preoperatively, 6 weeks, 6 months postoperatively using Oxford knee score, WOMAC score, Mancuso score, EQ-5D index, EQ-VAS, anxiety score, depression score, hospital anxiety and depression scale, respectively. Additionally, a rope pulley isokinetic system (Moflex, Recotec/Bernina, Switzerland) was applied to quantify the muscle strength preoperatively, 1 week, 6 weeks and 6 months postoperatively. RESULTS No difference in any of the outcome parameters could be observed between the groups at all time points after TKA (n.s.). Also the isokinetic muscle strength of the knee joint as quantified by concentric/eccentric peak force (N), workload (J), total workload (J) and power (W) did not reveal statistically significant differences between the groups and time points. However, in both groups improved results were found with respect to the functional outcome, patient satisfaction, health status and isokinetic muscle strength up to 6 months postoperatively. CONCLUSIONS The application of the tourniquet did not affect the isokinetic muscle strength, the functional outcome, the patient satisfaction and the health status following primary TKA. However, with and without tourniquet use, the level of the knee functionality, the patient satisfaction as well as the health status improved significantly. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Ahmed Jawhar
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Dania Skeirek
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Vera Stetzelberger
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Karl Kollowa
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Udo Obertacke
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| |
Collapse
|
9
|
Hossfeld B, Lechner R, Josse F, Bernhard M, Walcher F, Helm M, Kulla M. [Prehospital application of tourniquets for life-threatening extremity hemorrhage : Systematic review of literature]. Unfallchirurg 2019; 121:516-529. [PMID: 29797031 DOI: 10.1007/s00113-018-0510-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The effectiveness of a tourniquet in the case of life-threatening hemorrhages of the extremities is well recognized and led to the recommendations on "Tourniquet" of the German Society of Anaesthesiology and Intensive Care (DGAI) in 2016. The aim of this systematic review was to re-evaluate the current medical literature in relation to the published DGAI recommendations. MATERIAL AND METHODS Based on the analysis of all studies published from January 2015 until January 2018 in the PubMed databases, the publicized recommendations for action on "Tourniquet" of the DGAI were critically re-evaluated. For this purpose, 17 questions on 6 subjects were formulated in advance. The systematic review followed the PRISMA recommendations and is registered in PROSPERO (International prospective register of systematic reviews, Reg.-ID: CRD42018091528). RESULTS Of the 284 studies identified with the keywords tourniquet and trauma in the period from January 2015 to January 2018 in PubMed, 50 original papers discussing the prehospital application of tourniquet for life-threatening hemorrhage of the extremities were included. The overall level of evidence is low. No article addressed any of the formulated questions with a prospective randomized interventional study. Scientific deductions could be found only in an indirect way in a descriptive manner. CONCLUSION The 50 original articles included in this qualitative, systematic review revealed that the recommendations "Tourniquet" of the DGAI published in 2016 are mostly still up to date despite an inhomogeneous study situation. A deviation occurred in the conversion of a tourniquet but due to the short prehospital treatment time in the civilian setting this is of little importance; however, in the future a strict distinction should be made between tourniquets which were placed for tactical reasons and those placed as a medical necessity.
Collapse
Affiliation(s)
- B Hossfeld
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland.,Tactical Rescue and Emergency Medicine Association (TREMA e. V.), Tübingen, Deutschland
| | - R Lechner
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Tactical Rescue and Emergency Medicine Association (TREMA e. V.), Tübingen, Deutschland
| | - F Josse
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland.,Tactical Rescue and Emergency Medicine Association (TREMA e. V.), Tübingen, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland.,Arbeitsgruppe "Trauma- und Schockraummanagement", Arbeitskreis Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| | - F Walcher
- Universitätsklinik für Unfallchirurgie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland.,Sektion Notfall‑, Intensivmedizin und Schwerverletztenversorgung (NIS), Deutsche Gesellschaft für Unfallchirurgie (DGU), Berlin, Deutschland
| | - M Helm
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| | - M Kulla
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland. .,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland. .,Sektion Notfall‑, Intensivmedizin und Schwerverletztenversorgung (NIS), Deutsche Gesellschaft für Unfallchirurgie (DGU), Berlin, Deutschland.
| |
Collapse
|
10
|
Jawhar A, Brenner D, De La Torre C, Sticht C, Obertacke U, Ponelies N. Gene expression analysis of vastus medialis cells after tourniquet-induced ischemia during total knee arthroplasty: a randomized clinical trial. Eur J Trauma Emerg Surg 2019; 47:233-240. [PMID: 31385000 DOI: 10.1007/s00068-019-01196-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Postoperative quadriceps muscle strength was lowered after tourniquet application during total knee arthroplasty (TKA). Furthermore, tourniquet application results in higher proteolytic activity within vastus medialis cells, without influence on the amount and function of mitochondria. The effects of the commonly utilized intraoperative tourniquet on gene expression within the human skeletal muscle cells are barely examined. The purpose of the present study was to analyze the gene expression within the skeletal muscle cells after tourniquet-induced ischemia to identify differential expressed genes (DEGs) and pathways. METHODS As part of a randomized, controlled, monocentric trial (Clinical-Trials.gov NCT02475603) 20 patients, scheduled to undergo primary total knee arthroplasty (TKA), were included. Written informed consent was received and the patients were randomly assigned to Group A (TKA with tourniquet) (n = 10) and Group B (TKA without tourniquet) (n = 10). A muscle biopsie of (5 × 5 × 5 mm) 125 mm3 were obtained from the vastus medialis exactly 60 min after performing the surgical approach. After preparation of a muscle homogenate, RNA extraction was performed (RNeasy Plus Universal Mini Kit Qiagen) and RNA integrity (RIN) was determined (Agilent 2100 Bioanalyzer, RNA 6000 Pico Kit). Gene expression profiling was performed using a validated method (GeneChip™ Human Transcriptome Array 2.0; Affymetrix). Statistical analysis (SPSS-Version 24; SAS JMP10 Genomics, Version 6) included the number of significant DEGs (p < 0.05), the number of DEGs with relative difference > 25% and the number of significant pathway (p < 0.05). The serum C-reactive protein (CRP) and the white blood cell (WBC) count were also perioperatively measured. The protocol was approved by our Institutional Ethics Committee (File reference 2012-334N-MA). RESULTS Tourniquet application resulted in a total of 3555 (13.8%) statistically significant DEGs within vastus medialis cells. 76 DEGs (29 upregulated, 47 downregulated) revealed a relative difference of more than 25%. Statistically significant changes occurred in 59 (25.8%) of 229 analyzed pathways. Furthermore, there was no clinically meaningful difference between the groups with regard to CRP and WBC count. CONCLUSIONS Tourniquet induced ischemia results in significant changes of the gene expression within cells of vastus medialis including metabolism, genetic information processing and cellular processes. The identified altered expression of genes and pathways might serve as pharmacotherapeutical targets; although further research is needed to clarify the underlying biological processes. CLINICAL RELEVANCE These findings add further knowledge and should raise the awareness of surgeons about the effects of tourniquet induced ischemia at the gene expression level. Additional high-quality research may be warranted to examine the short and long term clinical significance of the present data. LEVEL OF EVIDENCE Level I.
Collapse
Affiliation(s)
- Ahmed Jawhar
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Desiree Brenner
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Carolina De La Torre
- Medical Research Center, Medical Faculty Mannheim, University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Carsten Sticht
- Medical Research Center, Medical Faculty Mannheim, University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Udo Obertacke
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Norbert Ponelies
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| |
Collapse
|
11
|
Wetzel MD, Wenke JC. Mechanisms by which hydrogen sulfide attenuates muscle function following ischemia-reperfusion injury: effects on Akt signaling, mitochondrial function, and apoptosis. J Transl Med 2019; 17:33. [PMID: 30665344 PMCID: PMC6340183 DOI: 10.1186/s12967-018-1753-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/21/2018] [Indexed: 01/24/2023] Open
Abstract
Ischemia–reperfusion injury is caused by a period of ischemia followed by massive blood flow into a tissue that had experienced restricted blood flow. The severity of the injury is dependent on the time the tissue was restricted from blood flow, becoming more severe after longer ischemia times. This can lead to many complications such as tissue necrosis, cellular apoptosis, inflammation, metabolic and mitochondrial dysfunction, and even organ failure. One of the emerging therapies to combat ischemic reperfusion injury complications is hydrogen sulfide, which is a gasotransmitter that diffuses across cell membranes to exert effects on various signaling pathways regulating cell survival such as Akt, mitochondrial activity, and apoptosis. Although commonly thought of as a toxic gas, low concentrations of hydrogen sulfide have been shown to be beneficial in promoting tissue survival post-ischemia, and modulate a wide variety of cellular responses. This review will detail the mechanisms of hydrogen sulfide in affecting the Akt signaling pathway, mitochondrial function, and apoptosis, particularly in regards to ischemic reperfusion injury in muscle tissue. It will conclude with potential clinical applications of hydrogen sulfide, combinations with other therapies, and perspectives for future studies.
Collapse
Affiliation(s)
- Michael D Wetzel
- US Army Institute of Surgical Research, Extremity Trauma and Regenerative Medicine, 3698 Chambers Pass BLDG 3611, Ft. Sam Houston, San Antonio, TX, 78234, USA
| | - Joseph C Wenke
- US Army Institute of Surgical Research, Extremity Trauma and Regenerative Medicine, 3698 Chambers Pass BLDG 3611, Ft. Sam Houston, San Antonio, TX, 78234, USA.
| |
Collapse
|
12
|
The Possible Pathophysiological Outcomes and Mechanisms of Tourniquet-Induced Ischemia-Reperfusion Injury during Total Knee Arthroplasty. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2018; 2018:8087598. [PMID: 30524661 PMCID: PMC6247434 DOI: 10.1155/2018/8087598] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022]
Abstract
Ischemia and reperfusion (I/R) injury induced by tourniquet (TQ) application leads to the release of both oxygen free radicals and inflammatory cytokines. The skeletal muscle I/R may contribute to local skeletal muscle and remote organ damage affecting outcomes after total knee arthroplasty (TKA). The aim of the study is to summarize the current findings associated with I/R injury following TKA using a thigh TQ, which include cellular alterations and protective therapeutic interventions. The PubMed database was searched using the keywords "ischemia reperfusion injury," "oxidative stress," "tourniquet," and "knee arthroplasty." The search was limited to research articles published in the English language. Twenty-eight clinical studies were included in this qualitative review. Skeletal muscle I/R reduces protein synthesis, increases protein degradation, and upregulates genes in cell stress pathways. The I/R of the lower extremity elevates local and systemic oxidative stress as well as inflammatory reactions and impairs renal function. Propofol reduces oxidative injury in this I/R model. Ischemic preconditioning (IPC) and vitamin C may prevent oxygen free radical production. However, a high dose of N-acetylcysteine possibly induces kidney injury. In summary, TQ-related I/R during TKA leads to muscle protein metabolism alteration, endothelial dysfunction, oxidative stress, inflammatory response, and renal function disturbance. Propofol, IPC, and vitamin C show protective effects on oxidative and inflammatory markers. However, a relationship between biochemical parameters and postoperative clinical outcomes has not been validated.
Collapse
|
13
|
Stetzelberger V, Obertacke U, Jawhar A. Tourniquet application during TKA did not affect the accuracy of implant positioning: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2018; 26:1728-1736. [PMID: 29058023 DOI: 10.1007/s00167-017-4760-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 10/12/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE The accuracy of the identification of anatomical landmarks with versus without tourniquet application and its effect on implant positioning remained unknown. Therefore, the hypothesis of the present study was that tourniquet application did not affect the accuracy of the reconstruction of the mechanical leg alignment, the joint line level, and the patellar height. METHODS The prospective randomized monocentric trial (Clinical-Trials.gov NCT02475603) included a total of 86 patients scheduled to undergo primary TKA. The patients were allocated to receive TKA with (Group A, n = 43) or without tourniquet (Group B, n = 43). The mechanical leg alignment, the joint line level (modified Kawamura), and the patellar height (Plateau-patella angle, Insall Salvati index, and modified Insall Salvati index) were measured pre- and postoperatively on standardized calibrated digital radiographs. Mean, SEM, median, range, and p value were calculated for each parameter. RESULTS There was no statistical difference between the groups with regard to demographics, preoperative deformity, implant design, and surgical technique (n.s.). The mechanical leg alignment, the joint line level, and the patellar height revealed, in both groups, similar results pre- and postoperatively (n.s.). CONCLUSION The mechanical leg alignment, the joint line level, and the patellar height could be accurately reconstructed with and without tourniquet use. With respect to clinically relevant surrogate parameters of implant positioning, TKA can safely be performed without a tourniquet. Available data do not support a routine use of tourniquet during TKA and might justify a change of the clinical pathway. LEVEL OF EVIDENCE Level I.
Collapse
Affiliation(s)
- Vera Stetzelberger
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Udo Obertacke
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ahmed Jawhar
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| |
Collapse
|
14
|
The Protective Effects of Fasciotomy on Reperfusion Injury of Skeletal Muscle of Rabbits. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7238960. [PMID: 28856161 PMCID: PMC5569626 DOI: 10.1155/2017/7238960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/06/2017] [Indexed: 11/17/2022]
Abstract
The authors aim to investigate protective effects of fasciotomy against ischemia reperfusion injury of skeletal muscle in rabbit and to compare the treatment effects of prereperfusion + fasciotomy and fasciotomy + postreperfusion against ischemia reperfusion injury of skeletal muscle. 24 healthy male Japanese white rabbits were randomly divided into 3 groups, and 4 hours' ischemia was established in these rabbits through surgery. Six hours' reperfusion was performed in group A; reperfusion + postfasciotomy was performed in group B; and prefasciotomy + reperfusion was performed in group C. Result showed that prefasciotomy and postfasciotomy could protect skeletal muscle against ischemia reperfusion injury, reduced MDA (malondialdehyde) expression, MPO (myeloperoxidase) expression, and apoptosis of muscle in the reperfused areas, increased Bcl-2 expression, and decreased Bax expression. The MDA and MPO levels in group B and group C were significantly lower than those in group A, and MDA and MPO levels in group C were significantly lower than those in group B. Prefasciotomy and postfasciotomy could protect against ischemia reperfusion injury in skeletal muscle. The protective effects of prefasciotomy against ischemia reperfusion injury are better than postfasciotomy.
Collapse
|