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Sivasubramanian H, Tan CMP, Wang L. Effects of local infiltration of analgesia and tranexamic acid in total knee replacements: safety and efficacy in reducing blood loss and comparability to intra-articular tranexamic acid. Singapore Med J 2024; 65:16-22. [PMID: 34617694 PMCID: PMC10863735 DOI: 10.11622/smedj.2021130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/03/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The use of periarticular (PA) tranexamic acid (TXA) and its efficacy in comparison with intra-articular (IA) TXA have not been well explored in the literature. This retrospective cohort study aimed to compare the effects of IA and PA TXA with analgesic components in reducing blood loss and improving immediate postoperative pain relief and functional outcomes in patients after unilateral primary total knee arthroplasty (TKA). METHODS A total of 63 patients underwent TKA, and they were divided into the IA TXA delivery group ( n = 42) and PA TXA delivery group ( n = 21). All patients were administered 1 g of TXA. They also received pericapsular infiltration consisting of 0.5 mL of adrenaline, 0.4 mL of morphine, 1 g of vancomycin, 1 mL of ketorolac and 15 mL of ropivacaine. Outcomes for blood loss and surrogate markers for immediate functional recovery were measured. RESULTS Of the 63 patients, 54% were female and 46% male. The mean drop in postoperative haemoglobin levels in the PA and IA groups was 2.0 g/dL and 1.6 g/dL, respectively, and this was not statistically significant ( P = 0.10). The mean haematocrit drop in the PA and IA groups was 6.1% and 5.3%, respectively, and this was also not statistically significant ( P = 0.58). The postoperative day (POD) 1 and discharge day flexion angles, POD 1 and POD 2 visual analogue scale (VAS) scores, gait distance on discharge and length of hospitalisation stay were largely similar in the two groups. CONCLUSION Our study showed that both IA and PA TXA with analgesic components were equally efficient in reducing blood loss and improving immediate postoperative pain relief and functional outcomes.
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Affiliation(s)
- Harish Sivasubramanian
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
| | - Cheryl Marise Peilin Tan
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
| | - Lushun Wang
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
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Ran W, Li S, Yuan R, Luo H, Li P, Gao J. Effect of tourniquet technique on postoperative delirium in elderly patients with total knee arthroplasty: a randomized single-blind controlled trial. BMC Anesthesiol 2022; 22:396. [PMID: 36539707 PMCID: PMC9764579 DOI: 10.1186/s12871-022-01938-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The tourniquet technique is often used in total knee arthroplasty (TKA). However, its effect on postoperative delirium (POD) in elderly patients undergoing TKA is unknown. METHODS: This prospective randomized controlled trial assessed the eligibility of 245 elderly patients. A total of 197 patients who met the inclusion criteria were randomly divided into a tourniquet group (n = 98) and a non-tourniquet group (n = 99). The primary outcome was the incidence of POD within 72 h after surgery. The secondary outcome was the quality of rehabilitation, including inflammatory reaction, postoperative pain, hypoproteinemia and anemia. RESULTS Of 245 patients, 184 patients completed this clinical trial, with 92 cases in each group. There were 14 patients (15.22%) with POD in the tourniquet group and 5 patients (5.43%) in the non-tourniquet group (95% CI 1.076 to 9.067, P = 0.029). The changes in white blood cell count (WBC), the proportion of neutrophils (NEUT%), c-reactive protein (CRP), interleukin-6 (IL-6) and middle patellar circumference in the tourniquet group were higher than those in the non-tourniquet group (P < 0.05). The visual analog scale (VAS) at rest and activity in the tourniquet group were higher than those in the non-tourniquet group (F = 170.102, P < 0.001 F = 75.391, P < 0.001). There were 41 (44.57%) patients with hypoproteinemia in the tourniquet group and 26 (28.26%) in the non-tourniquet group (95% CI 1.106 to 3.765, P = 0.022). CONCLUSION The application of the tourniquet technique in elderly patients with TKA procedures increased the incidence of POD. This may be attributed to the increased inflammatory reaction, severe postoperative pain and hypoproteinemia caused by the tourniquet technique. TRIAL REGISTRATION Clinical trial registration number: ChiCTR2100045711. Full date of the first registration: 23/04/2021.
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Affiliation(s)
- Wei Ran
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Shuzhen Li
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Ruixue Yuan
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Huan Luo
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Ping Li
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Jin Gao
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
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Kaseb MH, Moharrami A, Mirghaderi SP, Fallah E, Razzaghof M, Moazen Jamshidi MM, Poopak A, Mortazavi SMJ. Effect of joint immobilization using extension splint immediately after total knee arthroplasty on post-operative knee function and pain: a randomized clinical trial. INTERNATIONAL ORTHOPAEDICS 2022; 46:1749-1759. [PMID: 35587284 DOI: 10.1007/s00264-022-05428-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/01/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Investigate the effect of semirigid extension bracing after total knee arthroplasty (TKA) on articular pain and function. METHODS The present randomized clinical trial included 72 patients undergoing unilateral primary TKA. Patients in the case group received eight days of post-operative semirigid extension-locked knee bracing, whereas controls did not. The outcomes assessed preoperatively and on the first, ninth, 30th day, and one year post-operatively included the knee society score (KSS), functional KSS (FKSS), VAS pain score, amount of postoperative opiate painkiller usage (tablet oxycodone 5mg), and knee ROM. RESULTS The case group had a significantly lower flexion ROM on postoperative day nine compared to the control group (95.3° vs. 100.8°, p=0.03), while it became significantly higher 1 month (114.1° vs. 104.7°, p=0.03) and one year post-operative (128.0° vs. 120.5°, p=0.002). Also, FKSS was significantly higher in the case group than in the controls in the one month post-operative assessment (37.0 vs. 32.6, p=0.009) but not in the one year post-operative assessment. The case group patients had a significantly lower pain than the controls on days one (5.8 vs. 7.2, p=0.02) and nine post-operative (4.1 vs. 5.2, p=0.048), but not at later assessments. The amount of one month post-operative opium (oxycodone) consumption was significantly lower in the brace group (12.4 vs. 14.1 tablets, p=0.03). The KSS were not significantly different between the groups after the surgery. CONCLUSION Extension-locked splinting immediately after TKA is a noninvasive, non-pharmacological, and inexpensive intervention with possible promising effects on knee ROM, short-term functional improvement, and acute post-operative pain management.
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Affiliation(s)
- Mohammad Hasan Kaseb
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | - Alireza Moharrami
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | | | - Ehsan Fallah
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghof
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | | | - Amirhossein Poopak
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
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Chen Y, Qin L, Yang J, Wang J, Huang J, Gong X, Hu N. Changes in Thromboelastography to Predict Ecchymosis After Knee Arthroplasty: A Promising Guide for the Use of Anticoagulants. Front Surg 2022; 9:871776. [PMID: 35495763 PMCID: PMC9039049 DOI: 10.3389/fsurg.2022.871776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEcchymosis is one of the worrisome complications after total knee arthroplasty (TKA) and interferes with functional rehabilitation. Current clinical guidelines do not provide individualized approaches for patients with ecchymoses.MethodsIn this study, we used thromboelastography (TEG) to determine the coagulation state after TKA and to then explore markers that predict the occurrence of ecchymosis events after TKA. In our cohort, patients were divided into ecchymosis (n = 55) and non-ecchymosis (n = 137) groups according to whether ecchymosis events occurred after TKA. Rivaroxaban 10 mg/d was taken orally for thromboprophylaxis after surgery. All patients completed TEG testing. Correlation analysis was used to determine the risk factors for ecchymosis after TKA, and receiver operating characteristic (ROC) curves for variables with significant correlation were plotted.ResultsIn all, 55 of the 192 patients (28.65%) developed ecchymosis surrounding the surgical site. Multivariate analysis showed that hidden blood loss (OR = 1.003 and p = 0.005) and changes in the coagulation index (ΔCI) values (OR = 0.351 and p = 0.001) were risk factors for ecchymosis after TKA. Using the Youden index, 0.1805 was determined as the optimal threshold value of ΔCI for predicting the occurrence of ecchymosis, with a sensitivity of 74.55% and specificity of 72.99%. ΔCI is a promising marker as an alarm for the occurrence of ecchymosis after TKA.Trial RegistrationThe study was registered in the Chinese Clinical Trial Registry (ChiCTR1800017245). Registered name: The role of thrombelastography in monitoring the changes of coagulation function during perioperative period of arthroplasty. Registered 19 July 2018. http://www.chictr.org.cn/showproj.aspx?proj=29220
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Affiliation(s)
- Yuelong Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Leilei Qin
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianye Yang
- Department of Orthopaedics, Fuling Central Hospital, Chongqing, China
| | - Jiawei Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiaxing Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuan Gong
- Department of Outpatient Care, Chongqing General Hospital, Chongqing, China
- *Correspondence: Xuan Gong
| | - Ning Hu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Ning Hu
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Yang JQ, Yang L, Tan JS, Huo KP, Zhao L, Cai DZ. Reduction of Blood Loss by Intra-articular Injection of Tranexamic Acid Combined with Knee and Hip Flexion at 45° During Primary Total Knee Arthroplasty: A Randomized Controlled Trial. Orthop Surg 2020; 12:1835-1842. [PMID: 33094562 PMCID: PMC7767671 DOI: 10.1111/os.12814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 07/09/2020] [Accepted: 08/24/2020] [Indexed: 12/01/2022] Open
Abstract
Objective To explore the hemostatic effect of intra‐articular administration of tranexamic acid (TXA) combined with knee flexion in total knee arthroplasty (TKA). Methods This randomized controlled trial was conducted at the Third Affiliated Hospital of Southern Medical University (Guangzhou, China) from January 2017 to February 2018. The patients were randomized 1:1 to the TXA group (TXA 500 mg into the joint after closure, knee, and hip flexed at 45° for 4 h) or the control group (physiological saline, with limb fully extended). The primary endpoint was postoperative hemoglobin reduction. The postoperative levels of hemoglobin were measured at four time points: 6 h after operation, and on the first, second, and third postoperative days. Calculated blood loss (CBL) at 3 days, transfusion rate, range of motion (ROM), VAS pain score, and knee circumference increment were the secondary endpoints. Ninety‐four (47/group) patients were analyzed. Results Postoperatively, there were statistically significant differences between the TXA and control groups in CBL (791 ± 212 mL vs 1175 ± 273 mL, P < 0.05). Hemoglobin reduction was significantly lower in the TXA group (2.0 ± 0.9 g/dL vs 4.5 ± 0.7 g/dL, P < 0.05). Based on the transfusion criteria, 3 out of 47 (6.4%) patients in the TXA group and 13 out of 47 (27.6%) patients in the control group received blood transfusions (P = 0.006). ROM (90.8° ± 6.2° vs 87.6° ± 6.4°, P = 0.004), VAS pain score (4.1 ± 1.1 vs 4.8 ± 1.3, P = 0.004), and KCI (2.4 ± 0.9 cm vs 3.2 ± 1.0 cm, P = 0.01) were better in the TXA group compared with thecontrols. There was no deep venous thrombosis (DVT), wound infection or other adverse events in either group. In the control group, 2 patients had a fever after blood transfusion. Conclusion Intra‐articular injection of TXA combined with knee and hip flexion at 45° can effectively attenuate CBL and hemoglobin reduction during primary TKA, without an additional adverse event.
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Affiliation(s)
- Jian-Qi Yang
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China.,Department of Orthopaedics, The First People's Hospital of Foshan, Foshan, China
| | - Lin Yang
- Department of Orthopaedics, The First People's Hospital of Foshan, Foshan, China
| | - Jian-Shao Tan
- Department of Orthopaedics, The First People's Hospital of Foshan, Foshan, China
| | | | - Liang Zhao
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Dao-Zhang Cai
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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Yu R, Zhuo Y, Feng E, Wang W, Lin W, Lin F, Li Z, Lin L, Xiao L, Wang H, Huang Y, Wu C, Zhang Y. The effect of musical interventions in improving short-term pain outcomes following total knee replacement: a meta-analysis and systematic review. J Orthop Surg Res 2020; 15:465. [PMID: 33036637 PMCID: PMC7547446 DOI: 10.1186/s13018-020-01995-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A growing number of patients continue to receive total knee replacement (TKR) surgery. Nevertheless, such surgeries result in moderate to severe postoperative pain and difficulty in managing it. Musical interventions are regarded as a type of multimodal analgesia, achieving beneficial results in other clinical treatments. This study aims to evaluate the effect of musical interventions in improving short-term pain outcomes following TKR in order to determine a more reasonable and standard way of delivering musical intervention. METHODS A systematic search was conducted to identify available and relevant randomized controlled trials (RCTs) regarding musical interventions compared against non-musical interventions in patients treated with TKR in Embase, MEDLINE, Cochrane Library, Web of Science, CNKI, and Wanfang Med Online up to 8 January 2020. The authors independently assessed study eligibility and risk of bias and collected the outcomes of interest to analyze. The statistical analysis was conducted using the Review Manager (RevMan) version 5.30 software. RESULTS Eight RCTs comprised of 555 patients satisfied the inclusion criteria and were enrolled in the present study. The results showed no significant difference between the music and control groups in pain of the visual analog scale (VAS), during postoperative recovery room, back to the ward after surgery; anxiety degree of VAS; heart rate; respiratory rate; oxygen saturation; blood pressure, systolic blood pressure, and diastolic blood pressure. Nevertheless, significant differences were observed between the two groups in average increase in continuous passive motion (CPM) angles and LF/HF ratio (one kind index of heart rate variability). CONCLUSIONS Musical interventions fail to demonstrate an obvious effect in improving short-term pain outcomes following TKR. A reasonable standardization of musical interventions, including musical type, outcome measures used, outcomes measured, duration, timing and headphones or players, may improve pain outcomes with certain advantages and should be further explored after TKR.
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Affiliation(s)
- Rongguo Yu
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Youguang Zhuo
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Eryou Feng
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Wulian Wang
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Wentao Lin
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Feitai Lin
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Zhanglai Li
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Liqiong Lin
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Lili Xiao
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Haiyang Wang
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Yuting Huang
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Chunlin Wu
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China
| | - Yiyuan Zhang
- Department of Orthopedics, Fuzhou second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, China.
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Jette DU, Hunter SJ, Burkett L, Langham B, Logerstedt DS, Piuzzi NS, Poirier NM, Radach LJL, Ritter JE, Scalzitti DA, Stevens-Lapsley JE, Tompkins J, Zeni Jr J. Physical Therapist Management of Total Knee Arthroplasty. Phys Ther 2020; 100:1603-1631. [PMID: 32542403 PMCID: PMC7462050 DOI: 10.1093/ptj/pzaa099] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/24/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.
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Affiliation(s)
- Diane U Jette
- FAPTA, MGH, Institute of Health Professions, Boston, Massachusetts
| | - Stephen J Hunter
- FAPTA, MGH, Institute of Health Professions, Boston, Massachusetts
| | - Lynn Burkett
- ONC, National Association of Orthopaedic Nurses (NAON), Wyomissing, Pennsylvania
| | - Bud Langham
- Home Health and Hospice Services, Encompass Health, Birmingham, Alabama
| | - David S Logerstedt
- Department of Physical Therapy, University of the Sciences, Philadelphia, Pennsylvania
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Noreen M Poirier
- Department of Orthopedics and Rehabilitation, University of Wisconsin (UW) Health, Madison, Wisconsin
| | - Linda J L Radach
- Consumers United for Evidence Based Healthcare, Lake Forest Park, Washington
| | - Jennifer E Ritter
- Department of Rehabilitation Services/Physical Therapy, University of Pittsburgh Medical Center (UPMC) St Margaret Hospital/Catholic Relief Services, Pittsburgh, Pennsylvania
| | - David A Scalzitti
- OCS, School of Medicine and Health Sciences, George Washington University, Washington, DC
| | - Jennifer E Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, University of Colorado at Denver & Health Sciences Center, Denver, Colorado
| | - James Tompkins
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, Arizona
| | - Joseph Zeni Jr
- Department of Physical Therapy, University of Delaware, Newark, Delaware
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武 立, 吴 元, 斯 海, 曾 羿, 刘 渊, 杨 鹏, 沈 彬. [The influence of knee flexion position on postoperative blood loss and knee range of motion after total knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:524-528. [PMID: 32291993 PMCID: PMC8171521 DOI: 10.7507/1002-1892.201909058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/26/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To summarize research progress of the effect of knee flexion position on postoperative blood loss and knee range of motion (ROM) after total knee arthroplasty (TKA). METHODS The relevant literature at home and abroad was reviewed and summarized from mechanism, research status, progress, and clinical outcome. The differences of clinical results caused by different positions, flexion angles, and keeping time were compared. RESULTS Keeping knee flexion after TKA can reduce postoperative blood loss through the angle change of blood vessels and increase knee early ROM by improving flexion muscle strength. When the flexion angle of the knee is large and the flexion position is keeping for a long time, the postoperative blood loss and the knee ROM can be significantly improved. However, the amount of blood loss and ROM are not further improved in the patients with keeping knee flexion for more than 24 hours compared with less than 24 hours. CONCLUSION Keeping knee flexion after TKA is a simple and effective method to reduce postoperative blood loss and improve knee ROM. However, the optimal knee flexion angle and time are needed to be further explored.
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Affiliation(s)
- 立民 武
- 四川大学华西医院骨科(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
- 四川大学华西医院 国家老年疾病临床医学研究中心(成都 610041)National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 元刚 吴
- 四川大学华西医院骨科(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 海波 斯
- 四川大学华西医院骨科(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
- 四川大学华西医院 国家老年疾病临床医学研究中心(成都 610041)National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 羿 曾
- 四川大学华西医院骨科(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
- 四川大学华西医院 国家老年疾病临床医学研究中心(成都 610041)National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 渊 刘
- 四川大学华西医院骨科(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 鹏 杨
- 四川大学华西医院骨科(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 彬 沈
- 四川大学华西医院骨科(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Wang HY, Yu GS, Li JH, Zhang SX, Lin YB. An updated meta-analysis evaluating limb management after total knee arthroplasty-what is the optimal method? J Orthop Surg Res 2019; 14:97. [PMID: 30971262 PMCID: PMC6457036 DOI: 10.1186/s13018-019-1140-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 03/28/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose Postoperative knee flexion protocol has been widely recognized as a highly attractive, simple, and cost-effective tactic to improve patient’s outcomes after primary total knee arthroplasty (TKA). However, optimal knee position and duration of knee flexion are still controversial. The purpose of this meta-analysis was to compare the effectiveness of different postoperative knee flexion protocols, as an aid to find out optimal limb management strategy following TKA. Methods We conducted a meta-analysis to identify the available and relevant randomized controlled trials (RCTs) with regard to the influence of different postoperative knee positions on clinical outcomes after primary TKA in electronic databases, including PubMed, EMBASE, the Cochrane Library, Web of Science, CNKI, Wanfang Med Online, and VIP, up to May 2018. In this meta-analysis, three major subgroups based on diverse postoperative knee flexion protocols were considered: long-term (≥ 24 h) high flexion (> 30°), short term (< 24 h) high flexion (> 30°), and long-term (≥ 24 h) mild flexion (≤ 30°). The statistical analysis was performed using the Review Manager (RevMan) version 5.3 software. Results A total of 16 trials were finally included in this meta-analysis. The result of subgroup analysis indicated that keeping the knee in high flexion (> 30°) postoperatively for a long time (≥ 24 h) significantly reduced total blood loss (P < 0.00001), hidden blood loss (P < 0.00001), and transfusion requirements (P = 0.003) and led to a significant improvement in range of motion (ROM) at 1 week after operation (P < 0.00001); keeping the knee in high flexion (> 30°) postoperatively for a short time (< 24 h) significantly reduced total blood loss (P = 0.006) and hidden blood loss (P < 0.00001) but not significantly improved ROM at 1 week after operation (P = 0.34) and reduced transfusion requirements (P = 0.62); and keeping the knee in mild flexion (≤ 30°) postoperatively for a long time (≥ 24 h) significantly reduced total blood loss (P = 0.02) and transfusion requirements (P = 0.02) and improved ROM at 1 week after operation (P < 0.00001) but not significantly reduced hidden blood loss (P = 0.11). Furthermore, there was no significant difference with respect to the rates of wound-related infection and DVT between the three knee flexion subgroups. Conclusions This meta-analysis showed that the long-term (≥ 24 h) high flexion (> 30°) protocol could be an optimal limb management to reduce blood loss and blood transfusion requirements and facilitate early postoperative rehabilitation exercises in patients after primary TKA without increasing in complication rate.
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Affiliation(s)
- Hai-Yang Wang
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Guang-Shu Yu
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Jie-Hui Li
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Shou-Xiong Zhang
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Yan-Bin Lin
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China.
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Yuenyongviwat V, Tuntarattanapong P, Iamthanaporn K, Hongnaparak T, Tangtrakulwanich B. Intramedullary sealing with a bone plug in total knee arthroplasty to reduce blood loss: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2019; 14:96. [PMID: 30961640 PMCID: PMC6454759 DOI: 10.1186/s13018-019-1141-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/28/2019] [Indexed: 11/18/2022] Open
Abstract
Background An intramedullary guide is an instrument that surgeons use to align the distal femoral cut. The opening may become a channel that drains intramedullary blood to the knee joint after surgery if left open during surgery. The authors aimed to evaluate the effects of an intramedullary bone plug with respect to postoperative blood loss from a meta-analysis. Methods The authors performed a systematic review and meta-analysis to compare a sealed opening using an intramedullary bone plug with no bone plug. PubMed, Ovid, Embase, and Cochrane Library were used to identify all publications before May 2018. All of the included studies were evaluated for bias and heterogeneity. Results Six hundred and thirty-six patients from four randomized controlled trials were included in this meta-analysis. The pooled results demonstrated that patients with intramedullary plug had lower rates of blood transfusion and lower level of reduced postoperative hemoglobin than patients in whom the intramedullary canal was not plugged. Discussion This meta-analysis demonstrated the benefit of intramedullary sealing with a bone plug in total knee arthroplasty with respect to decreased postoperative blood loss.
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Affiliation(s)
- Varah Yuenyongviwat
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Pakjai Tuntarattanapong
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Khanin Iamthanaporn
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Theerawit Hongnaparak
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Boonsin Tangtrakulwanich
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Wu Y, Lu X, Ma Y, Zeng Y, Xiong H, Bao X, Shen B. Efficacy and safety of limb position on blood loss and range of motion after total knee arthroplasty without tourniquet: A randomized clinical trial. Int J Surg 2018; 60:182-187. [PMID: 30468901 DOI: 10.1016/j.ijsu.2018.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/26/2018] [Accepted: 11/07/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the effect of postoperative limb position on blood loss and knee function after primary total knee arthroplasty without tourniquet. MATERIAL AND METHODS One hundred patients were randomly assigned into 2 groups: Group A was given a knee flexion position at 60° for 24 h after surgery but without the tourniquet use. Patients in group B was received the tourniquet use the same flexion position as the Group A. All patients received intravenous (IV) tranexamic acid (TXA) 15 mg/kg before skin incision and another 1 g of IV-TXA after 3 h. RESULTS The total blood loss was similar in the 2 groups. Group A had significantly less hidden blood loss and drainage volume (P = 0.023, P < 0.001), and higher intraoperative blood loss than the Group B (P < 0.001). The visual analog scale and knee circumference in Group A were lower than the Group B on postoperative days 1, 3 and 5. The range of motion was also lowering in Group A than the Group B on postoperative days 1, 3, 5 and at the 1 month. No significant differences (P > 0.05) were observed between the 2 groups regarding maximum hemoglobin drop, transfusion rate, postoperative hospital stay, DVT and/or PE, and wound-related complications. CONCLUSION Based on the current evidence, patients treated with postoperative limb positions without a tourniquet can effectively reduce hidden blood loss and drainage volume, as well as better early clinical benefits than those treated with a tourniquet. LEVEL OF EVIDENCE Therapeutic Level I.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Xiaoxi Lu
- Department of Pediatrics, West China University Second Hospital, Sichuan University, Chengdu, Sichuan Province, 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, China.
| | - Yimei Ma
- Department of Pediatrics, West China University Second Hospital, Sichuan University, Chengdu, Sichuan Province, 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, China.
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Huazhang Xiong
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Xianchao Bao
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
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The effect of post-operative limb positioning on blood loss and early outcomes after primary total knee arthroplasty: a randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2018; 43:2083-2091. [DOI: 10.1007/s00264-018-4174-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/18/2018] [Indexed: 11/24/2022]
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Zeng Y, Si H, Li C, Wu Y, Shen B. Effect of knee flexion position and combined application of tranexamic acid on blood loss following primary total knee arthroplasty: a prospective randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2018; 42:529-535. [PMID: 29396806 DOI: 10.1007/s00264-018-3808-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/23/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this study was to demonstrate the association between tranexamic acid (TXA)-combined application and knee flexion in the first 24 hour post-operatively that could reduce total blood loss and transfusion need in patients undergoing total knee arthroplasty (TKA), without sacrificing safety. METHODS Ninety TKA patients were divided into three groups randomly: the flexion group: the knee was in 90° flexion position for the first 12 hour post-surgery and kept at 60°for the next 12 hour, combined with 1 g TXA topical and 1 g TXA intravenous application. The extension group: the knee was in fully extension position post-operatively, combined with topical and intravenous TXA application. The controlled group: the knee was in fully extension position post-operatively combined with single intravenous TXA application. The primary outcomes included blood loss variables and transfusion values. The secondary outcomes included post-operative hospital stay, knee flexion degree, complication rate, and hospital charge. RESULTS The total blood loss and transfusion needs in the flexion group were significantly reduced in comparison with that in the extension group and controlled group. The post-operative knee flexion motion was significant higher in the flexion group than the other two groups. There was no difference among the three groups with regard to the rates of complications. CONCLUSIONS Keeping the knee in flexion position combined with topical and intravenous TXA application in patients undergoing primary unilateral TKA significantly reduced post-operative bleeding and the transfusion rate compared with what was found after treatment with extension knee position or single intravenous TXA application. LEVEL OF EVIDENCE Therapeutic Level I.
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Affiliation(s)
- Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Canfeng Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China.
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Zhou K, Ling T, Wang H, Zhou Z, Shen B, Yang J, Kang P, Pei F. Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. J Orthop Surg Res 2017; 12:172. [PMID: 29137681 PMCID: PMC5686948 DOI: 10.1186/s13018-017-0683-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 10/29/2017] [Indexed: 02/05/2023] Open
Abstract
Background We aimed to compare the effect of tourniquet use or lack of it on recovery following uncomplicated primary total knee arthroplasty (TKA). Methods In a prospective randomised double-blinded study, 150 patients undergoing primary TKA were assigned to either a tourniquet or non-tourniquet group. At the early phase, 3 and 6 months after surgery, an independent observer assessed the primary outcome measure (i.e. total blood loss) and secondary outcome measures (i.e. wound complications, visual analogue scale pain score and knee range of motion). Results The tourniquet group exhibited reduced intraoperative blood loss (215.7 ± 113.7 ml vs. 138.6 ± 93.9 ml, P < 0.001) and shorter operating time (77.2 ± 14.5 min vs. 82.0 ± 12.7 min, P = 0.038). However, the non-tourniquet group showed less postoperative blood loss (180.2 ± 117.0 ml vs. 253.7 ± 144.2 ml, P = 0.001) and drainage volume (89.2 ± 66.3 ml vs. 164.5 ± 97.8 ml, P = 0.004), less thigh pain (all P < 0.001) in the initial 3 weeks, better knee range of motion (ROM) in the initial 3 days (day 1 81.6 ± 17.1 vs. 75.95 ± 14.55, P = 0.036; day 3 99.8 ± 13.7 vs. 93.95 ± 11.15, P = 0.005) and fewer wound tension vesicles (10.3 vs. 29.2%, P = 0.005). Earlier straight-leg raising (4.6 ± 3.8 h vs. 6.4 ± 4.3 h, P = 0.01) and shorter length of stay (6.3 ± 1.7 days vs. 7.1 ± 1.9 days, P = 0.001) were found in the non-tourniquet group. Similar total blood loss and blood transfusion rate were observed for both groups. All other parameters revealed no significant differences. Conclusions Our study suggests that a non-tourniquet TKA would lead to early rehabilitation without increasing side effects. Trial registration Chinese Clinical Trials Registry, ChiCTR-IOR-16007851, 1/29/2016
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Affiliation(s)
- Kai Zhou
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Tingxian Ling
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Haoyang Wang
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zongke Zhou
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Bin Shen
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Jing Yang
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Pengde Kang
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Fuxing Pei
- Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, 610041, China
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What is the optimal approach for tranexamic acid application in patients with unilateral total hip arthroplasty? DER ORTHOPADE 2017; 45:616-21. [PMID: 27142970 DOI: 10.1007/s00132-016-3252-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE In the total hip arthroplasty (THA), the optimal administration route of tranexamic acid (TXA) remains controversial. This study was designed to investigate the impact of topical injection of TXA on blood loss during primary unilateral THA as well as short-term safety and adverse side effects compared with intravenous administration of TXA. MATERIAL AND METHODS In this study, 75 patients who underwent unilateral THA were randomly divided into 3 groups receiving intra-articular TXA (IA group), intravenous TXA (IV group) or no TXA (control group C). Blood loss, postoperative drainage, covert blood loss, total blood volume, the number of blood transfusions after surgery and transfusion rate, incidence of deep venous thrombosis and pulmonary embolism were recorded and evaluated in the three groups after 1 week and 1 month. RESULTS There were significant differences in the quantity of postoperative drainage, covert blood loss, total blood volume, the number of blood transfusions after surgery and transfusion rates between the three groups (P < 0.05), but blood loss during surgery showed no significant differences among the three groups (P > 0.05). In the IV group, 1 patient suffered from deep venous thrombosis of the lower limbs and in the C group, 2 patients suffered from superficial venous thrombosis of the lower limbs 2 and 4 days after surgery, respectively. In the IA group no complications occurred during the follow-up period. CONCLUSION Preoperative intravenous TXA and postoperative topical TXA significantly reduced postoperative blood loss and transfusion rates among the patients who underwent primary unilateral THA and the short-term safety was good. The data suggest that topical injection of TXA is safer and more effective, without postoperative complications.
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Wang K, Ni S, Li Z, Zhong Q, Li R, Li H, Ke Y, Lin J. The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 2017; 25:2849-2857. [PMID: 26745962 DOI: 10.1007/s00167-015-3964-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 12/23/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Tourniquets are still widely used in total knee arthroplasty (TKA), although they may be associated with several adverse effects. An observer-blinded, randomized, controlled trial was performed to evaluate the effects of tourniquet use in TKA. METHODS Fifty participants who underwent staged bilateral TKA were recruited for this study. The first-side TKA was randomly allocated to either long-duration tourniquet use or short-duration tourniquet use followed by a 3-month washout period and crossover to the other tourniquet strategy for the opposite-side TKA. Blood loss was monitored perioperatively. The operating time, allogeneic blood transfusion rate, thigh pain, knee pain, limb swelling, clinical outcome as measured by the Likert-type Western Ontario and McMaster University (WOMAC) score, straight leg raising and knee active range of motion (ROM) were also recorded. RESULTS The long-duration tourniquet group exhibited reduced total blood loss [-99.1 ml, 95 % confidence interval (CI) -168.1 to -30.1, P = 0.0411] and intraoperative blood loss (-225.2 ml, 95 % CI -369.5 to -80.9, P = 0.0071) compared with the short-duration tourniquet group. However, there were greater postoperative blood loss (69.6 ml, 95 % CI 21.1 to 118.2, P = 0.0282) and hidden blood loss (52.8 ml, 95 % CI 10.5 to 95.1, P = 0.0332) in the long-duration tourniquet group. The short-duration tourniquet group showed better outcomes for thigh and knee pain, limb swelling, WOMAC score at 6-week follow-up, straight leg raising and knee ROM. Similar allogeneic blood transfusion rates were observed for both groups. CONCLUSION Total and intraoperative blood losses were reduced with the long-duration tourniquet use, whereas the short-duration tourniquet use would reduce postoperative and hidden blood losses without increasing the allogeneic blood transfusion rate. In addition, short-duration tourniquet use would result in faster recovery and less pain during the early rehabilitation period following TKA. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Kai Wang
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Songjia Ni
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Zhichang Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Qunjie Zhong
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Rujun Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Hu Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Yan Ke
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Jianhao Lin
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China.
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De Fine M, Traina F, Giavaresi G, Leo E, Sanzarello I, Perna F, Dattola R, Faldini C. Effect of different postoperative flexion regimes on the outcomes of total knee arthroplasty: randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2017; 25:2972-2977. [PMID: 27056697 DOI: 10.1007/s00167-016-4119-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 03/29/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE A consistent limb position strategy could be an attractive and easier alternative to reduce blood loss and increase range of motion following total knee arthroplasty. The aim of this study was to understand the proper amount of flexion required to improve functional outcomes with limited patients' discomfort. METHODS Eighty-five patients undergoing total knee arthroplasty were randomly assigned to receive mild (30° of knee flexion) or high-flexion protocol (70° of knee flexion), 48 h after surgery. The same daily rehabilitation scheme was followed. Total blood loss, hidden blood loss, haemoglobin and haematocrit levels, fixed flexion deformity, range of motion and limb circumference at the superior patellar pole were evaluated preoperatively and 7 days after surgery. RESULTS Demographics, blood parameters and preoperative range of motion did not show any significant difference between the two groups. No complications were recorded in both groups. High-flexion group had greater rate of dropout due to excessive patients' discomfort. A significantly lower Hb at day 1 was found in the high-flexion group. No differences were recorded regarding the remaining parameters. CONCLUSION No significant differences were found between the high-flexion and mild-flexion protocols; however, mild-flexion protocol was better tolerated by patients. We therefore recommend a 30° flexion protocol to be routinely used 48 h postoperatively after total knee arthroplasty. This is an easy strategy to improve functional outcomes, which is a fundamental issue considering the steady increase in knee prostheses utilization. LEVEL OF EVIDENCE Randomized controlled trial, Level II.
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Affiliation(s)
- Marcello De Fine
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy.
| | - Francesco Traina
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
| | - Gianluca Giavaresi
- Laboratory of Preclinical and Surgical Studies, Rizzoli Orthopedic Institute, Bologna, Italy
- Laboratory of Tissue Engineering - Innovative Technology Platforms for Tissue Engineering, Rizzoli Orthopedic Institute, Palermo, Italy
| | - Eugenio Leo
- Rehabilitation Service, University of Messina, Messina, Italy
| | - Ilaria Sanzarello
- Section of Orthopaedics and Traumatology, Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Fabrizio Perna
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
| | - Roberto Dattola
- Rehabilitation Service, University of Messina, Messina, Italy
| | - Cesare Faldini
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
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Jiang C, Lou J, Qian W, Ye C, Zhu S. Impact of flexion versus extension of knee position on outcomes after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2017; 137:257-265. [PMID: 28028616 PMCID: PMC5250658 DOI: 10.1007/s00402-016-2613-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Controversy still exists regarding positioning of the knee in flexion or in extension after total knee arthroplasty (TKA) impacts treatment outcomes. In this meta-analysis, we evaluated if a postoperative knee position regime could positively affect the rehabilitation. METHODS A comprehensive search for randomized controlled trials (RCTs) assessing the effect of knee positioning after TKA was conducted. The outcomes of interest were blood loss and range of motion (ROM); total calculated blood loss (CBL), drainage volume, hidden blood loss (HBL), decline of hemoglobin level and requirement for blood transfusion. RESULTS Ten RCTs involving 962 knees were eligible for meta-analysis. Positioning the knee in flexion after TKA was significantly associated with lesser CBL (P < 0.00001), less HBL (P < 0.00001) and decreased requirement for blood transfusion (P = 0.06). On subgroup analyses, the flexion group was found to have significantly less decrease in hemoglobin level 48 h to 6 days after surgery (P = 0.003), while no significant difference was noted at 24 h after surgery (P = 0.29). Further,a superior ROM was observed in flexion group (5-7 days after surgery) (P = 0.002), while there was no significant difference at 6 weeks. No significant inter-group difference in wound drainage was observed at 24 h after surgery. CONCLUSION Positioning the knee in flexion in the early postoperative stage was associated with significantly lesser CBL, lesser HBL, decreased requirement for blood transfusion and better ROM at least in the early postoperative period, which may contribute to early rehabilitation. However, no significant difference was found in ROM at 6 weeks.
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Affiliation(s)
- Chao Jiang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 100730 Beijing, China
| | - Jieqiong Lou
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Wenwei Qian
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 100730 Beijing, China
| | - Canhua Ye
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 100730 Beijing, China
| | - Shibai Zhu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 100730 Beijing, China
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Wu Y, Yang T, Zeng Y, Si H, Li C, Shen B. Effect of different postoperative limb positions on blood loss and range of motion in total knee arthroplasty: An updated meta-analysis of randomized controlled trials. Int J Surg 2016; 37:15-23. [PMID: 27913236 DOI: 10.1016/j.ijsu.2016.11.135] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/16/2016] [Accepted: 11/27/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative limb positioning has been reported to be an efficient and simple way to reduce blood loss and improve range of motion following total knee arthroplasty (TKA). This meta-analysis was designed to compare the effectiveness of two different limb positions in primary TKA. MATERIALS AND METHODS A meta-analysis of the PubMed, CENTRAL, Web of Science, EMBASE and Google Search Engine electronic databases was performed. In this meta-analysis, two postoperative limb positions were considered: mild-flexion (flexion less than 60°) and high-flexion (flexion at 60° or more). The subgroups were analysed using RevMan 5.3. RESULTS Nine RCTs were included with a total sample size of 913 patients. The mild- and high-flexion positions significantly reduced postoperative total blood loss (P = 0.04 and P = 0.01; respectively). Subgroup analysis indicated that knee flexion significantly reduced hidden blood loss when the knee was fixed in mild-flexion (P = 0.0004) and significantly reduced transfusion requirements (P = 0.03) and improved range of motion (ROM) (P < 0.00001) when the knee was fixed in high-flexion. However, the rates of wound-related infection, deep venous thrombosis (DVT) and pulmonary embolism (PE) did not significantly differ between the two flexion groups. CONCLUSION This meta-analysis suggests that mild- and high-flexion positions have similar efficacy in reducing total blood loss. In addition, subgroup analysis indicates that the mild-flexion position is superior in decreasing hidden blood loss compared with high-flexion; the high-flexion position is superior to mild-flexion in reducing transfusion requirements and improving postoperative ROM. Thus, the use of the high-flexion position is a viable option to reduce blood loss in patients following primary TKA without increasing the risk of wound-related infection, DVT or PE.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Timin Yang
- Department of Orthopaedic Surgery, People's Hospital of Tibet Autonomous Region, Lasa, 850000, China.
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Canfeng Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
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Pichonnaz C, Bassin JP, Lécureux E, Christe G, Currat D, Aminian K, Jolles BM. Effect of Manual Lymphatic Drainage After Total Knee Arthroplasty: A Randomized Controlled Trial. Arch Phys Med Rehabil 2016; 97:674-82. [DOI: 10.1016/j.apmr.2016.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 12/21/2015] [Accepted: 01/02/2016] [Indexed: 11/30/2022]
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21
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Liu N, Luo S, Hang C, Zha Z, Li J, Wu W, Hou D. Changes in coagulation functions and hemorheological parameters may predict hematoma formation after total knee arthroplasty. J Orthop Surg Res 2016; 11:35. [PMID: 27013496 PMCID: PMC4806485 DOI: 10.1186/s13018-016-0370-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/16/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Hematoma formation around the knee is commonly seen after total knee arthroplasty (TKA) and may cause patient discomfort and worry regarding the success of the surgery. This study aimed to evaluate the coagulation functions and hemorheological parameters in patients undergoing TKA and investigate their associations with hematoma formation. METHODS This study prospectively included 146 patients treated for knee osteoarthritis by unilateral TKA between August 2013 and August 2014. Apixaban was administered twice during the 12-24-h period after surgery. Blood coagulation functions were evaluated according to activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time, and fibrinogen preoperatively and on postoperative days 1, 3, 7, and 14. Hemorheological parameters were also measured. Patients were divided into a hematoma group and a non-hematoma group for comparison. RESULTS On postoperative day 1, the hematoma group showed significantly prolonged APTT and PT and significantly decreased hematocrit relative to baseline values (P < 0.05). The whole blood high shear rate, whole blood low shear rate, plasma viscosity, and hematocrit did not differ significantly between the two groups at baseline or from postoperative days 1-14 in (P > 0.05). CONCLUSIONS Prolonged APTT and PT on the first day after TKA as well as decreased hematocrit may indicate an increased risk of hematoma formation. Postoperative use of apixaban may promote the formation of ecchymoses but is not a major contributing factor.
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Affiliation(s)
- Ning Liu
- The First Affiliated Hospital, Jinan University, Guangzhou, 510632, China.,Institute of Orthopaedic Disease Research, Jinan University, Guangzhou, 510632, China
| | - Simin Luo
- The First Affiliated Hospital, Jinan University, Guangzhou, 510632, China.,Institute of Orthopaedic Disease Research, Jinan University, Guangzhou, 510632, China
| | - Cheanglek Hang
- Macau Medical Science & Technology Research Association, Macau, China
| | - Zhengang Zha
- The First Affiliated Hospital, Jinan University, Guangzhou, 510632, China. .,Institute of Orthopaedic Disease Research, Jinan University, Guangzhou, 510632, China.
| | - Jieruo Li
- The First Affiliated Hospital, Jinan University, Guangzhou, 510632, China.,Institute of Orthopaedic Disease Research, Jinan University, Guangzhou, 510632, China
| | - Wenrui Wu
- The First Affiliated Hospital, Jinan University, Guangzhou, 510632, China.,Institute of Orthopaedic Disease Research, Jinan University, Guangzhou, 510632, China
| | - Dabiao Hou
- The First Affiliated Hospital, Jinan University, Guangzhou, 510632, China.,Institute of Orthopaedic Disease Research, Jinan University, Guangzhou, 510632, China
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Chen ZY, Wu HZ, Zhu P, Feng XB. Postoperative Changes in Hemoglobin and Hematocrit in Patients Undergoing Primary Total Hip and Knee Arthroplasty. Chin Med J (Engl) 2016; 128:1977-9. [PMID: 26168841 PMCID: PMC4717940 DOI: 10.4103/0366-6999.160620] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Hai-Zhao Wu
- Department of Joint Surgery, Taizhou Hospital, Linhai, Zhejiang 317000, China
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Fu X, Tian P, Li ZJ, Sun XL, Ma XL. Postoperative leg position following total knee arthroplasty influences blood loss and range of motion: a meta-analysis of randomized controlled trials. Curr Med Res Opin 2016; 32:771-8. [PMID: 26783114 DOI: 10.1185/03007995.2016.1142431] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIM Postoperative leg position has been reported as an efficient and convenient technique to minimize blood loss and improve early recovery following total knee arthroplasty (TKA); however, no single study was large enough to definitively determine optimal leg position. Therefore, we performed a meta-analysis pooling the results from randomized controlled trials (RCTs) to evaluate the effect of postoperative leg position on blood loss and range of motion (ROM) in TKA. METHODS Potential academic articles were identified from the Cochrane Library, Medline (1966-October 2015), PubMed (1966-October 2015), Embase (1980-October 2015), ScienceDirect (1985-October 2015) and other databases. Gray studies were identified from the references of included literature reports. The pooling of data was analyzed by RevMan 5.1. RESULTS Ten RCTs were included in the meta-analysis. There were significant differences in the total blood loss (mean difference [MD] = -130.66, 95% CI: -198.74 to -62.57, P = 0.0002), hidden blood loss (MD = -73.27, 95% CI: -117.57 to -28.96, P = 0.001), blood transfusion requirement (risk difference [RD] = -0.10, 95% CI: -0.19 to -0.22, P = 0.02), postoperative hemoglobin level (MD = 0.73, 95% CI: 0.42 to 1.04, P < 0.00001) and range of motion (MD = 3.79, 95% CI: 1.43 to 6.14, P = 0.002) between the flexion group and extension group. No significant differences were found regarding length of hospital stay, deep vein thrombosis (DVT) and wound infection between the two groups. CONCLUSIONS This meta-analysis indicated that the postoperative flexion position of the leg in TKA was effective and safe, significantly decreasing total blood loss, hidden blood loss and blood transfusion requirement. In addition, the postoperative range of motion is significantly improved by the flexion position of the leg.
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Affiliation(s)
- Xin Fu
- a Tianjin Hospital , Tianjin , China
| | - Peng Tian
- a Tianjin Hospital , Tianjin , China
| | - Zhi-jun Li
- b General Hospital of Tianjin Medical University , Tianjin , China
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Thienpont E, Lavand'homme P, Kehlet H. The constraints on day-case total knee arthroplasty: the fastest fast track. Bone Joint J 2015; 97-B:40-4. [PMID: 26430085 DOI: 10.1302/0301-620x.97b10.36610] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Total knee arthroplasty (TKA) is a major orthopaedic intervention. The length of a patient's stay has been progressively reduced with the introduction of enhanced recovery protocols: day-case surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case TKA. These constraints may be social, linked to patient's comorbidities, or due to surgery-related adverse events (e.g. pain, post-operative nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and multimodal opioid-sparing analgesia, day-case TKA might be achievable in a limited group of patients. The younger, male patient without comorbidities and with an excellent social network around him might be a candidate. Demographic changes, effective recovery programmes and less invasive surgical techniques such as unicondylar knee arthroplasty, may increase the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced against any increase in morbidity and mortality and the cost of advanced follow-up at a distance with new technology. These factors need to be evaluated before adopting this ultimate 'fast-track' approach.
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Affiliation(s)
- E Thienpont
- Catholic University of Louvain Cliniques Universitaires St-Luc, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - P Lavand'homme
- Catholic University of Louvain Cliniques Universitaires St-Luc, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - H Kehlet
- Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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25
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Wong KL, Peter L, Liang S, Shah S, Johandi F, Wang W. Changes in dimensions of total knee arthroplasty anterior knee dressings during flexion: Preliminary findings. Int J Orthop Trauma Nurs 2015; 19:179-83. [PMID: 26547680 DOI: 10.1016/j.ijotn.2015.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 05/14/2015] [Accepted: 06/18/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Wound care is critical to the management of patients post total knee arthroplasty, requiring prudent selection of dressings that can accommodate changes in wound length during knee flexion. This study aims to quantify differences in dressing dimensions based on the position of the knee during the application of the dressing and subsequent flexion. METHODS Our study involved 40 knees divided into 2 groups, an extension group and a flexion group, each consisting of 20 knees. These groups had dressings applied to the knee in full extension and in 90° of flexion respectively. Measurements of the dressings were taken for the extension group with the knee in extension and for both groups at 90° of flexion. RESULTS For the extension group, the changes in length and breadth of the dressings when measured in 90° of flexion were 3.42 ± 0.15 cm, p < 0.001 and -0.43 ± 0.10 cm, p < 0.001 respectively. Compared to the flexion group, the differences in length and breadth between the dressings when measured in 90° of flexion were 3.48 ± 0.15 cm, p < 0.001 and -0.14 ± 0.12 cm, p < 0.001 respectively. CONCLUSION There are significant differences and changes in the dimensions of knee dressings depending on the position of the knee during the application of dressing and subsequent flexion.
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Affiliation(s)
- Keng Lin Wong
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Luke Peter
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore.
| | - Shen Liang
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Siddharth Shah
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Faisal Johandi
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Wilson Wang
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
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Pichonnaz C, Bassin JP, Lécureux E, Currat D, Jolles BM. Bioimpedance spectroscopy for swelling evaluation following total knee arthroplasty: a validation study. BMC Musculoskelet Disord 2015; 16:100. [PMID: 25907994 PMCID: PMC4422299 DOI: 10.1186/s12891-015-0559-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 04/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The evaluation of swelling is important for the outcome of total knee arthroplasty (TKA) surgery. The circumference or volume measurements are applicable at the bedside of the patient but are altered by muscular atrophy and the post-surgical dressing. Bioimpedance spectroscopy might overcome these limitations; however, it should be validated. This study aimed to explore the validity, the reliability and the responsiveness of bioimpedance spectroscopy for measuring swelling after TKA. METHODS The degree of swelling in 25 patients undergoing TKA surgery was measured using bioimpedance spectroscopy (BIS R0), knee circumference and limb volume. The measurements were performed on D-1 (day before surgery), D + 2 (2 days after surgery) and D + 8 (8 days after surgery). The BIS R0 measurements were repeated twice, alternating between two evaluators. The percentage of the difference between the limbs was calculated for BIS R0, circumference and volume. The intra- and inter-observer intraclass correlation coefficients (ICCs), limits of agreement (LOA), effect size (Cohen's d), correlations between the methods and diagnostic sensitivity were calculated. RESULTS BIS R0, circumference and volume detected swelling < 3.5% at D-1. The swelling at D2 and D8 was greater with BIS R0 [mean (SD) 29.9% (±9.8) and 38.27 (±7.8)] than with volume [14.7 (±9.5) and 14.9 (±8.2)] and circumference [11.1 (±5.7) and 11.7 (±4.1)]. The BIS R0 intra- and inter-evaluator ICCs ranged from 0.89 to 0.99, whereas the LOA were < 5.2%. The BIS R0 correlation was 0.73 with volume and 0.75 with circumference. The BIS R0 Cohen's d was 3.32 for the D-1-D2 evolution. The diagnostic sensitivity was 83% D2 and 96% at D8. CONCLUSION Bioimpedance is a valid method for the evaluation of swelling following TKA. BIS R0 also demonstrated excellent intra- and inter-evaluator reliability. The diagnostic sensitivity and responsiveness is superior to that of concurrent methods. BIS R0 is an efficient method for post-surgical follow up at the bedside of the patient. The measurement of BIS R0 is a straightforward, valid, reliable and responsive method for lower limb swelling following TKA surgery that could be used in clinics and research. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00627770.
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Affiliation(s)
- Claude Pichonnaz
- Physiotherapy Department, Haute Ecole de Santé Vaud (HESAV), HES-SO, University of Applied Sciences Western Switzerland, Delémont, Switzerland. .,CHUV-UNIL, Orthopedics and Traumatology Department, CHUV-UNIL, Avenue du Bugnon 21, 1011, Lausanne, Switzerland.
| | - Jean-Philippe Bassin
- Physiotherapy Department, Haute Ecole de Santé Vaud (HESAV), HES-SO, University of Applied Sciences Western Switzerland, Delémont, Switzerland.
| | - Estelle Lécureux
- CHUV-UNIL, direction médicale, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Damien Currat
- Physiotherapy Department, Haute Ecole de Santé Vaud (HESAV), HES-SO, University of Applied Sciences Western Switzerland, Delémont, Switzerland.
| | - Brigitte M Jolles
- CHUV-UNIL, Orthopedics and Traumatology Department, CHUV-UNIL, Avenue du Bugnon 21, 1011, Lausanne, Switzerland.
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Post-operative limb position can influence blood loss and range of motion after total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015; 23:852-9. [PMID: 24682489 DOI: 10.1007/s00167-013-2732-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE A consistent post-operative limb positioning regime could be an attractive, simple and cost-effective alternative to improve patient's outcomes after total knee arthroplasty (TKA). The aim of this study was to perform a systematic review of the available literature in order to understand whether a consistent post-operative limb positioning regime could affect blood loss and range of motion (ROM) after TKA. METHODS A search was performed using the keywords "total knee replacement/knee prosthesis" in combination with "post-operative management", "blood loss", "range of motion", "leg position", "flexion", "extension" and "splinting" regardless of the year of publication. The scientific databases have been accessed in order to identify papers dealing with post-operative limb positioning regimes after TKA. RESULTS Seven articles matching the inclusion criteria were selected. Blood loss and ROM were both investigated in all but one paper, in which only blood loss was evaluated. There were six randomized controlled trials and one prospective comparative study. A 48-72 h post-operative knee flexion protocol seems to be effective in reducing blood loss and increasing ROM following TKA. We did also find no benefit in using extension splints in the immediate post-operative period. CONCLUSIONS Based on the studies undertaken to date, a 48-72 h post-operative knee flexion protocol should be implemented as an easy and inexpensive method of reducing blood loss and increasing ROM following TKA. Shorter flexion regimes failed to influence these parameters.
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Kömürcü E, Yüksel HY, Ersöz M, Aktekin CN, Hapa O, Çelebi L, Akbal A, Biçimoğlu A. Effect of surgical closing in total knee arthroplasty at flexion or extension: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 2014; 22:3067-73. [PMID: 24519622 DOI: 10.1007/s00167-014-2896-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 02/03/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to evaluate the effect of knee position during wound closure (flexed vs. extended) in total knee arthroplasty on knee strength and function, as determined by knee society scores and isokinetic testing of extensor and flexor muscle groups. METHODS In a prospective, randomized, double-blind trial, 29 patients were divided in two groups: for Group 1 patients, surgical closing was performed with the knee extended, and for Group 2 patients, the knee flexed at 90°. All the patients were treated with the same anaesthesia method, surgical team, surgical technique, prosthesis type, and rehabilitation process. American Knee Society Score values and knee flexion degrees were recorded. Isokinetic muscle strength measurements of both knees in flexion and extension were taken using 60° and 180°/s angular velocity. The peak torque and total work values, isokinetic muscle strength differences, and total work difference values were calculated for surgically repaired and healthy knees. RESULTS No significant difference in the mean American Knee Society Score values and knee flexion degrees was observed between the two groups. However, using isokinetic evaluation, a significant difference was found in the isokinetic muscle strength differences and total work difference of the flexor muscle between the two groups when patients were tested at 180°/s. Less loss of strength was detected in the isokinetic muscle strength differences of the flexor muscle in Group 2 (-4.2%) than in Group 1 (-23.1%). CONCLUSION For patients undergoing total knee arthroplasty, post-operative flexor muscle strength is improved if the knee is flexed during wound closure. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Erkam Kömürcü
- Department of Orthopedics and Traumatology, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey,
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Knee flexion after total knee arthroplasty reduces blood loss. Knee Surg Sports Traumatol Arthrosc 2014; 22:1859-64. [PMID: 24718736 DOI: 10.1007/s00167-014-2983-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 04/01/2014] [Indexed: 01/30/2023]
Abstract
PURPOSE Extensive blood loss after total knee arthroplasty (TKA) may be a potential problem since it leads to anaemia, increased need for transfusion and prolonged hospitalization. Aim of this study was to investigate the effects of postoperative knee flexion after TKA on blood loss and the need for transfusion. METHODS One hundred consecutive patients undergoing primary TKA from 2012 to 2013 were randomizely divided into two groups. In one group, the knee was extended for the first 6 h after surgery, whereas in the other was flexed at 90° for the same time. Two doses of endovenous tranexamic acid were administered in all subjects. Patients were homogeneous for all the possible confounding factors. RESULTS Calculated blood loss was 846 ± 197 (ml) in the flexion group and 1,242 ± 228 (ml) in the extension group (p < 0.05). Drop of haemoglobin levels at 24 h in the study group and the control group was 1.9 ± 0.8 (g/dl) and 3.0 ± 0.5 (g/dl), respectively (p < 0.01). Drop of haematocrit at 24 h was 4.5 ± 0.2 (%) in the flexion group and 6.7 ± 0.3 (%) in the extension group (p < 0.05). Blood transfusion was necessary in 5 patients in the control group and was not necessary in any patient of the study group. Average knee flexion at day 7 was 105° ± 4° in the flexion group and 98° ± 7° in the extension group. CONCLUSION Knee flexion at 90° after TKA, associated with the intraoperative use of tranexamic, acid is an effective method to reduce blood loss and the need for blood transfusion. The routine use of the present protocol is effective in reducing social costs and length of hospitalization of TKA procedures.
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Napier RJ, Bennett D, McConway J, Wilson R, Sykes AM, Doran E, O'Brien S, Beverland DE. The influence of immediate knee flexion on blood loss and other parameters following total knee replacement. Bone Joint J 2014; 96-B:201-9. [PMID: 24493185 DOI: 10.1302/0301-620x.96b2.32787] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In an initial randomised controlled trial (RCT) we segregated 180 patients to one of two knee positions following total knee replacement (TKR): six hours of knee flexion using either a jig or knee extension. Outcome measures included post-operative blood loss, fall in haemoglobin, blood transfusion requirements, knee range of movement, limb swelling and functional scores. A second RCT consisted of 420 TKR patients randomised to one of three post-operative knee positions: flexion for three or six hours post-operatively, or knee extension. Positioning of the knee in flexion for six hours immediately after surgery significantly reduced blood loss (p = 0.002). There were no significant differences in post-operative range of movement, swelling, pain or outcome scores between the various knee positions in either study. Post-operative knee flexion may offer a simple and cost-effective way to reduce blood loss and transfusion requirements following TKR. We also report a cautionary note regarding the potential risks of prolonged knee flexion for more than six hours observed during clinical practice in the intervening period between the two trials, with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy at their three-month review.
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Affiliation(s)
- R J Napier
- Musgrave Park Hospital, Orthopaedic Outcomes Unit, Belfast Health & Social Care Trust, Stockmans Lane, Belfast BT9 7JB, UK
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Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2014; 9:13. [PMID: 24602486 PMCID: PMC3973857 DOI: 10.1186/1749-799x-9-13] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 02/11/2014] [Indexed: 11/16/2022] Open
Abstract
Background The purpose of this research is to evaluate the effects of a tourniquet in total knee arthroplasty (TKA). Methods The study was done by randomized controlled trials (RCTs) on the effects of a tourniquet in TKA. All related articles which were published up to June 2013 from Medline, Embase, and Cochrane Central Register of Controlled Trails were identified. The methodological quality of the included studies was assessed by the Physiotherapy Evidence Database (PEDro) scale. The meta-analysis was performed using Cochrane RevMan software version 5.1. Results Thirteen RCTs that involved a total of 689 patients with 689 knees were included in the meta-analysis, which were divided into two groups. The tourniquet group included 351 knees and the non-tourniquet group included 338 knees. The meta-analysis showed that using a tourniquet in TKA could reduce intraoperative blood loss (weighted mean difference (WMD), -198.21; 95% confidence interval (CI), -279.82 to -116.60; P < 0.01) but did not decrease the calculated blood loss (P = 0.80), which indicates the actual blood loss. Although TKA with a tourniquet could save the operation time for 4.57 min compared to TKA without a tourniquet (WMD, -4.57; 95% CI, -7.59 to -1.56; P < 0.01), it had no clinical significance. Meanwhile, the use of tourniquet could not reduce the possibility of blood transfusion (P > 0.05). Postoperative knee range of motion (ROM) in tourniquet group was 10.41° less than that in the non-tourniquet group in early stage (≤10 days after surgery) (WMD, -10.41; 95% CI, -16.41 to -4.41; P < 0.01). Moreover, the use of a tourniquet increased the risk of either thrombotic events (risk ratio (RR), 5.00; 95% CI, 1.31 to 19.10; P = 0.02) or non-thrombotic complications (RR, 2.03; 95% CI, 1.12 to 3.67; P = 0.02). Conclusions TKA without a tourniquet was superior to TKA with a tourniquet in thromboembolic events and the other related complications. There were no significant differences between the two groups in the actual blood loss. TKA with a tourniquet might hinder patients' early postoperative rehabilitation exercises.
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Affiliation(s)
| | | | | | | | | | - Liaobin Chen
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.
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Fibrin sealants in orthopaedic surgery: practical experiences derived from use of QUIXIL® in total knee arthroplasty. Arch Orthop Trauma Surg 2012; 132:1147-52. [PMID: 22526196 DOI: 10.1007/s00402-012-1519-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Indexed: 02/09/2023]
Abstract
BACKGROUND Total knee arthroplasty is associated with a significant postoperative blood loss even without any form of perioperative anticoagulation. METHODS The potential role of QUIXIL(®), a fibrin sealant used in orthopaedic surgery to control blood loss and avoid blood transfusions in patients undergoing total knee arthroplasty was evaluated in a prospective randomized trial with twenty-four patients diagnosed with primary osteoarthritis of the knee. RESULTS Results showed that application of 2 ml QUIXIL(®) adds costs to treatment without reducing the number of transfused red blood cell counts and postoperative haemoglobin loss. However, significant lower levels of postoperative fluid loss (P = 0.026) was detected in QUIXIL(®) treated patients. CONCLUSION Regarding cost effectiveness and benefit no indication for the use of 2 ml QUIXIL(®) fibrin sealant in standard knee arthroplasty could be proofed statistically.
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