Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial

Comparison of the clinical outcomes following total knee arthroplasty in osseous ankylosed and non-ankylosed knees using propensity-score matching

OBJECTIVES

Few studies have compared the clinical outcomes and complications of total knee arthroplasty (TKA) in patients with and without osseous ankylosed knees. Thus, we investigated the clinical outcomes and complications of TKA in patients with osseous ankylosed knees using a propensity-score matching method.

METHODS

Thirteen knees in the osseous ankylosed-knees group and 13 knees in the non-ankylosed-knees group were included after excluding those with less than 2 years of follow-up or a lack of data and after propensity-score matching. The American Knee Society Score-knee (AKSS-knee), AKSS-function, knee-flexion angle, knee-extension angle, knee range of motion (ROM) before and after TKA, and the number of knees with postoperative complications were evaluated as primary outcomes.

RESULTS

The AKSS-knee, AKSS-function, knee-flexion angle, and knee ROM in the osseous ankylosed-knees group after TKA were significantly lower than those in the non-ankylosed-knees group. The knee-extension angle after TKA and number of knees with postoperative complications within 2 years were not significantly different between the two groups.

CONCLUSIONS

The clinical results of TKA in patients with osseous ankylosed knees were inferior to those in patients with non-ankylosed knees.

Efficacy of combining intravenous and topical dexamethasone against postoperative pain and function recovery after total knee arthroplasty: A prospective, double-blind, randomized controlled trial

BACKGROUND

Dexamethasone is a corticosteroid with powerful anti-inflammatory effects. This study aimed to explore whether combining intravenous and topical dexamethasone could improve postoperative pain, swelling, and function recovery after total knee arthroplasty (TKA).

METHODS

In this prospective, double-blind, randomized controlled study, 90 patients undergoing primary unilateral TKA were randomized into a dexamethasone group, which received dexamethasone (10 mg) by periarticular infiltration during surgery, as well as intravenous dexamethasone (10 mg) before tourniquet release and at 12 h postoperatively; or a control group, which received equal volumes of isotonic saline instead of dexamethasone. The primary outcome was postoperative pain, as assessed on the visual analogue scale (VAS). Secondary outcomes were postoperative consumption of morphine hydrochloride for rescue analgesia, postoperative swelling ratio of the thigh, knee, and tibia; functional recovery in terms of total range of motion (ROM) of knee and daily ambulation distance; postoperative inflammation biomarkers levels of C-reactive protein and interleukin-6; and postoperative complications.

RESULTS

Resting VAS scores at postoperative 6, 12, and 24 h, and VAS scores during motion at postoperative 2, 6, 12, and 24 h were significantly lower in the dexamethasone group. The dexamethasone group also showed significantly less morphine consumption during the first 24 h after surgery and cumulatively during hospitalization, milder limb swelling at 24 and 48 h postoperatively, greater flexion and total ROM on postoperative day 1, and longer ambulation distance on postoperative days 1 and 2, and lower levels of inflammatory biomarkers on postoperative days 1 and 2. The dexamethasone group had significantly lower incidence of postoperative nausea and vomiting.

CONCLUSION

Compared with placebo, the combination of intravenous and topical dexamethasone can reduce pain, swelling, and inflammation after TKA, it also can improve functional recovery and reduce the incidence of postoperative nausea and vomiting.

Characterizing tourniquet induced hemodynamics during total knee arthroplasty using diffuse optical spectroscopy

Tourniquet use creates a reduced blood surgical field during total knee arthroplasty (TKA), however, prolonged ischemia may cause postoperative tourniquet complications. To understand the effects of tourniquet-induced ischemia, we performed a prospective observational study using quantitative broadband diffuse optical spectroscopy (DOS) to measure tissue hemodynamics and water and lipid concentrations before, during, and after tourniquet placement in subjects undergoing TKA. Data was collected for 6 months and, of the total subjects analyzed (n = 24), 22 were primary TKAs and 2 were revision TKA cases. We specifically investigated tourniquet-induced hemodynamics based upon subject-specific tissue composition and observed a significant relationship between the linear rate of deoxygenation after tourniquet inflation and water/lipid ratio (W/L, p < 0.0001) and baseline somatic tissue oxygen saturation, StO2 (p = 0.05). Subjects with a low W/L ratio exhibited a lower tissue metabolic rate of oxygen consumption, (tMRO2 ) (p = 0.008). Changes in deoxyhemoglobin [HbR] (p = 0.009) and lipid fraction (p = 0.001) were significantly different between high and low W/L subject groups during deoxygenation. No significant differences were observed for hemodynamics during reperfusion and total tourniquet time was neither significantly related to the hemodynamic hyperemic response (p = 0.73) nor the time to max StO2 after tourniquet release (p = 0.57). In conclusion, we demonstrate that DOS is capable of real-time monitoring of tissue hemodynamics distal to the tourniquet during TKA, and that tissue composition should be considered. DOS may help surgeons stratify hemodynamics based upon tissue composition and eventually aid the preoperative risk assessment of vascular occlusions from tourniquet use during TKA.

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

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.

Tourniquet Use Is Associated With Reduced Blood Loss and Fewer Reoperations in Aseptic Revision Total Knee Arthroplasty

BACKGROUND

Although tourniquet use in primary total knee arthroplasty (TKA) has been widely studied, the outcomes associated with tourniquet use in revision TKA (rTKA) remains relatively unexplored. This study investigates surgical outcomes and patient satisfaction in association with tourniquet use during aseptic rTKA.

METHODS

We retrospectively reviewed all patients who underwent rTKA for aseptic causes at our institution from 2011 to 2020. Patients were separated into 2 cohorts based on tourniquet inflation during the procedure. Outcomes of interest included estimated blood loss, change in hemoglobin, surgical time, length of stay, reoperation rate, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores.

RESULTS

Of the 1212 patients included, 1007 (83%) underwent aseptic rTKA with the use of a tourniquet and 205 (17%) without the use of a tourniquet. The mean tourniquet inflation time was 93.0 minutes (standard deviation 33.3 minutes). Blood loss was significantly less for patients in the tourniquet cohort as measured through estimated blood loss (224.1 vs 325.1 mL, P < .001) and change in preoperative to postoperative hemoglobin (1.75 vs 2.04 g/dL, P < .001). There were no statistical differences in surgical time (P = .267) and length of stay (P = .206) between the 2 groups. The reoperation rate was significantly greater for patients who did not have a tourniquet utilized (20.5% vs 15.0%, P = .038). Delta improvement in KOOS, JR scores from baseline to 3 months postoperatively did not statistically differ between the 2 cohorts (P = .560).

CONCLUSION

Although delta improvements in KOOS, JR scores were similar for both cohorts, patients who did not have a tourniquet inflated during aseptic rTKA had increased blood loss and were more likely to undergo subsequent reoperation compared to patients who did.

LEVEL III EVIDENCE

Retrospective Cohort Study.

The effects of tourniquet on cement penetration in total knee arthroplasty

PURPOSE

Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant's "strength" and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients.

METHODS

A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies.

RESULTS

A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2-4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0-4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02).

CONCLUSION

Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.

Effect of tourniquet use on blood loss, pain, functional recovery, and complications in robot-assisted total knee arthroplasty: a prospective, double-blinded, randomized controlled trial

Background

Robot-assisted total knee arthroplasty (TKA) has been largely studied to confirm its advantages in terms of accurate component positioning, microembolus formation, less blood loss, and so on, but is currently usually performed under tourniquet due to its longer operative time than conventional TKA. The aim of this study was to estimate the effects of tourniquet use in robot-assisted TKA on blood loss, pain, functional recovery, and complications.

Methods

Patients scheduled for robot-assisted TKA were prospectively randomized into a tourniquet or non-tourniquet group (each n = 14). The primary outcome measure was blood loss. The secondary outcome measures were operation time; visual analog scale (VAS) pain scores; time to achieve the first straight-leg raise; swelling of the thigh, knee, and calf; range of motion; Hospital for Special Surgery score; length of stay; and postoperative complications.

Results

There was no significant difference in total blood loss between the tourniquet and non-tourniquet groups (738.57 ± 276.158 vs. 866.85 ± 243.422 ml, P = 0.061). The tourniquet group showed significantly lower intraoperative blood loss (P < 0.001), but higher hidden blood loss (P = 0.002). The non-tourniquet group showed better knee range of motion on postoperative days (PODs) 1–3 (all P < 0.001), less thigh swelling on PODs 2 and 3 (P < 0.05), earlier straight-leg raising (P = 0.044), and shorter length of stay (P = 0.044). Thigh pain VAS score at 1 month after surgery was significantly greater in the tourniquet group (P < 0.001), as was knee pain during activity and at rest on PODs 2–3 (all P < 0.05). The tourniquet group also showed a significantly higher rate of tension blisters (28.8% vs. 7.1%, P = 0.038).

Conclusions

Tourniquet use during robot-assisted TKA does not reduce total blood loss, and it appears to increase postoperative pain, aggravate muscle injury, and prolong postoperative recovery.

Trial registration ChiCTR, ChiCTR2100041800. Registered 5 January 2021, http://www.chictr.org.cn/index.aspx.

Hypotensive Anesthesia Combined with Tranexamic Acid Reduces Perioperative Blood Loss in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Cohort Study

OBJECTIVE

To assess the efficacy and safety of hypotensive anesthesia (HA) combined with tranexamic acid (TXA) for reducing perioperative blood loss in simultaneous bilateral total hip arthroplasty (SBTHA).

METHODS

In this retrospective cohort study, a total of 183 eligible patients (15 females and 168 males, 44.01 ± 9.29 years old) who underwent SBTHA from January 2015 to September 2020 at our medical center were enrolled for analysis. Fifty-nine patients received standard general anesthesia (Std-GA group), the other 85 and 39 patients received HA with an intraoperative mean arterial pressure between 70 and 80 mmHg (70-80 HA group) and below 70 mmHg (<70 HA group), respectively. TXA was administrated to all patients. Perioperative blood loss (total, dominant, and hidden), transfusion rate and volume, hemoglobin and hematocrit reduction, duration of operation and anesthesia, length of hospitalization, range of hip motion as well as postoperative complications were collected from hospital's electronic records and compared between groups.

RESULTS

All patients were followed for more than 3 months. Total blood loss in the two HA groups (1390.25 ± 595.67 ml and 1377.74 ± 423.46 ml, respectively) was significantly reduced compared with that in Std-GA group (1850.83 ± 800.73 ml, P < 0.001). Both dominant and hidden blood loss were dramatically decreased when HA was applied (both P < 0.001). Accordingly, the transfusion rate along with volume in 70-80 HA group (14.1%, 425.00 ± 128.81 ml) and <70 HA group (12.8%, 340.00 ± 134.16 ml) were reduced in comparison with those in Std-GA group (37.3%, 690.91 ± 370.21ml; P = 0.001 and P = 0.014, respectively). The maximal hemoglobin and hematocrit reduction in both HA groups were significantly less than those in Std-GA group (both P < 0.001). Of note, 70-80 and <70 HA groups exhibited comparable efficacy with no significant differences between them. Besides, significant difference in duration of surgery was found among groups (P = 0.044 and P < 0.001), while no differences in anesthesia time and postoperative range of hip motion were observed. Regarding complications, the incidence of both acute kidney injury and postoperative hypotension in <70 HA group was significantly higher than that in 70-80 HA and Std-GA groups (P = 0.014 and P < 0.001). Incidence of acute myocardial injury was similar among groups (P = 0.099) and no other severe complications or mortality were recorded.

CONCLUSION

The combination of HA with a mean arterial pressure (MAP) of 70-80 mmHg and TXA could significantly reduce blood loss and transfusion during SBTHA, in addition to shortening operation time and length of hospitalization, and with no increase in complications.

Impact of tourniquet during total knee arthroplasty when tranexamic acid was used: a meta-analysis of randomized controlled trials

Introduction

The efficacy of tourniquet use during primary total knee arthroplasty (TKA) is thought to reduce intraoperative blood loss, improve surgical exposure, and optimize cement fixation. Tranexamic acid (TXA) use can decrease postsurgical blood loss and transfusion requirements. This review aimed to appraise the effects of tourniquet use in TKA for patients with tranexamic acid use.

Methods

A meta-analysis was conducted to identify relevant randomized controlled trials involving TXA plus a tourniquet (TXA-T group) and use of TXA plus no tourniquet (TXA-NT group) in TKA. Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database were searched from 2010 through October 2021.

Results

We identified 1720 TKAs (1690 patients) assessed in 14 randomized controlled trials. Compared with the TXA-NT group, the TXA-T group resulted in less intra-operative blood loss (P < 0.00001) and decreased duration of surgery (P < 0.00001), however more hidden blood loss (P = 0.0004) and less knee range of motion (P < 0.00001). No significant differences were found between two groups in terms of decrease in hemoglobin (P = 0.84), total blood loss (P = 0.79), transfusion rate (P = 0.18), drainage volume (P = 0.06), Visual Analogue Scale (VAS) at either the day of surgery (P = 0.2), 1 day (P = 0.25), 2 day (P = 0.39), 3 day (P = 0.21), 5 day (P = 0.21), 7 day (P = 0.06) or 1 month after surgery (P = 0.16), Hospital for Special Surgery (HSS) score at either 7 day (P = 0.10), 1 month (P = 0.08), 3 month (P = 0.22) or 6 month after the surgery (P = 0.92), Knee circumference (P = 0.28), length of hospital (P = 0.12), and complications such as intramuscular venous thrombosis (P = 0.81), deep venous thrombosis (P = 0.10), superficial infection (P = 0.45), deep wound infection (P = 0.64), and delayed wound healing (P = 0.65).

Conclusion

No big differences could be found by using or not tourniquet when use the TXA, though some benefits are related to operation time and less intra-operative blood loss by using tourniquet and TXA, Using the tourniquet was related to more hidden blood loss and less knee range of motion. More adequately powered and better-designed randomized controlled trials (RCTs) studies with long-term follow-up are required to validate this study.

Comparison of efficacy and safety of different tourniquet applications in total knee arthroplasty: a network meta-analysis of randomized controlled trials

OBJECTIVE

Total knee replacement (TKA) is an effective way to treat teratogenic and disabling knee diseases such as advanced osteoarthritis. Tourniquets are often used in TKA to reduce bleeding and to get a better visualization of the surgical field, while it is related to safety concerns. We did this network meta-analysis to comprehensively compare the efficacy and safety of various tourniquet application strategies.

METHOD

PubMed, Embase, Cochrane Library, CNKI, and WanFang Database were systematically searched from January 1990 to May 2020. A network meta-analysis with a frequentist framework was done to assess the relative efficacy and safety by comparing seven clinical important endpoints.

RESULTS

38 eligible studies that assessed 3007 participants who underwent TKA were included in this network meta-analysis. Tourniquet inflation before osteotomy then deflation after wound closure effectively reduce perioperative bleeding (WMD compared with control group -234.66, 95% CI [-409.19 to -60.13]), while shortening the operation time (WMD -8.98, 95%CI [-14.07 to -3.88]) and reducing postoperative complications, including DVT (OR -0.58, 95%CI [-1.19 to 0.03]) and minor wound complications (OR -1.38, 95%CI [-3.00 to 0.25]). No difference was found in the late postoperative knee pain and function outcomes.

CONCLUSIONS

Using tourniquets during the entire operation can effectively reduce blood loss, but it also can cause many safety problems, including DVTs, wound oozing, delayed healing, and serious wound complications. Tourniquet inflation before osteotomy then deflation after wound closure effectively can reduce perioperative bleeding while shortening the operation time and reducing postoperative complications, so it could be the ideal tourniquet application strategy in TKA.Key messagesThis is the first study that comprehensively compared different tourniquet application strategies to evaluate their impact on postoperative recovery following TKA, and five clinically important endpoints were assessed in this study: perioperative blood loss, operation time, postoperative pain and function, and complications.We conclude that tourniquet inflation before osteotomy then deflation after wound closure could be the ideal tourniquet application strategy in TKA.

Safety of Total Knee Arthroplasty without Using a Tourniquet in Elderly Patients

This study retrospectively compared the perioperative bleeding, hemodynamics, and clinical outcomes of total knee arthroplasty (TKA) performed with and without a tourniquet between two age groups. We grouped 103 patients with knee osteoarthritis who underwent primary TKA based on age at surgery: <76 years and ≥76 years. Tourniquet was used for TKA until March 2010 and stopped thereafter; hence, the patients were further classified according to TKA performed with or without a tourniquet. The differences in the operation time; perioperative bleeding; estimated bleeding; and hemoglobin (Hb) and hematocrit (Ht) levels immediately, 1 day, and 7 days postoperatively were evaluated. The clinical outcomes for range of motion, and Knee Society Knee Scores preoperatively and at 4 weeks postoperatively were assessed. Operation time was longer in the ≥76-year-old non-tourniquet group. No difference was observed in estimated bleeding among the groups. Changes in the Hb and Ht levels at postoperative days 1 and 7 were negatively correlated with age but were not different for TKA performed with or without a tourniquet in the ≥76-year-old-patient group. There were no differences in clinical outcomes among the groups. TKA can be performed with or without a tourniquet in patients aged ≥ 76 years with careful assessment of postoperative anemia.

Modified Robert Jones Bandage in reducing blood loss in total knee arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this meta-analysis was to assess the effects of Modified Robert Jones Bandage (MRJB) in primary total knee arthroplasty (TKA).

METHODS

PubMed, EMBASE, the Cochrane Library, Web of Science, and Google Scholar were systematically searched for randomized controlled trials (RCTs). All RCTs were compared to receive either MRJB (study group) or conventional wound dressing (control group) in TKA. Statistical analysis was assessed using RevMan 5.3 software.

RESULTS

A total of 5 RCTs involving 362 patients were included in the meta-analysis. No significant difference between the 2 groups was found in terms of total blood loss (Mean difference [MD], -25.41; 95% confidence interval [CI], -90.52 to 39.70; P = .44), intra-operative blood loss (MD, -13.77; 95% CI, -31.84 to 4.29; P = .14), drain blood loss (MD, 0.83; 95% CI, -30.07 to 31.72; P = .96), and transfusion rate (risk ratio, 0.95; 95% CI, 0.55-1.64; P = .86); There was also no significant difference in terms of range of motion (MD, -0.93; 95% CI, -3.64 to 1.79; P = .50), visual analog scale pain sores (MD, -0.02; 95% CI, -0.34 to 0.30; P = .90), and operative time (MD, -3.12; 95% CI, -13.42 to 7.18; P = .55), without increasing the risk of wound-related complications (risk ratio, 0.75; 95% CI, 0.27-2.08; P = .58) in both groups. No deep venous thrombosis occurred in all studies.

CONCLUSIONS

The current meta-analysis of the available evidence indicates patients with MRJB had not required the additional advantage compared to the conventional wound dressing for TKA. However, more high-quality studies are needed to confirm the above conclusions.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Effectiveness and Safety of Tourniquet Application Strategies in Total Knee Arthroplasty: a Meta-analysis

BACKGROUND

We conducted the present meta-analysis to assess the effectiveness and safety of long-duration tourniquet and short-duration tourniquet for patients with total knee arthroplasty (TKA).

METHODS

Published randomized controlled trials (RCTs) were identified from the following electronic databases: PubMed, Embase, Web of Science and Cochrane Library from inception to January 1, 2021. Studies comparing long-duration tourniquet and short-duration tourniquet in total knee arthroplasty were included. Either a random-effects model or a fixed-effects model was used for meta-analysis depending on the heterogeneity. Statistical analysis was assessed using RevMan 5.3 software.

RESULTS

A total of 8 RCTs with a total of 484 patients were eligible and ultimately included in the meta-analysis. Compared with patients in the long-duration tourniquet, those in the short-duration tourniquet were significantly correlated with postoperative drainage volume (WMD = -71.85, 95% CI - 76.52 to - 67.17, P = 0.31), but an increased risk of total blood loss (WMD = 68.13, 95% CI 5.15-131.12, P = 0.03) and intraoperative blood loss (WMD = 137.13, 95% CI 69.06-205.20, P < 0.00001). Two groups showed no significant difference in operation time, visual analogue scale score of knee in early, transfusion rate and incidence of deep venous thrombosis.

CONCLUSIONS

Our meta-analysis suggested that the short-duration tourniquet in TKA significantly decreased the postoperative drainage volume, increased the total blood loss and intraoperative blood loss. However, it did not marked decrease the occurrence of transfusion rate. Although the incidence of deep venous thrombosis was reduced in some study, it was not statistically significant. Additional high quality RCTs are needed to identify the hypothesis. Therefore, we recommend prolonged use of tourniquets during TKA surgery.

Does the Use of a Tourniquet Influence Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Intraoperative tourniquet use in total knee arthroplasty (TKA) is a common practice which may improve visualization of the surgical field and reduce blood loss. However, the safety and efficacy associated with tourniquet use continues to be a subject of debate among orthopedic surgeons. The primary purpose of this study is to evaluate the effects of tourniquet use on pain and opioid consumption after TKA.

METHODS

This is a multicenter randomized controlled trial among patients undergoing TKA. Patients were preoperatively randomized to undergo TKA with or without the use of an intraoperative tourniquet. Frequency distributions, means, and standard deviations were used to describe baseline patient demographics (age, gender, race, body mass index, smoking status), length of stay, surgical factors, visual analog scale pain scores, and opioid consumption in morphine milligram equivalents.

RESULTS

A total of 327 patients were included in this study, with 166 patients undergoing TKA without a tourniquet and 161 patients with a tourniquet. A statistically significant difference was found in surgical time (97.87 vs 92.98 minutes; P = .05), whereas none was found for length of stay (1.73 vs 1.70 days; P = .87), postop visual analog scale pain scores (1.73 vs 1.70; P = .87), inpatient opioid consumption (19.84 vs 19.27 morphine milligram equivalents; P = .74), or outpatient opioid consumption between the tourniquet-less and tourniquet cohorts, respectively. There were no readmissions in either cohort during the 90-day episode of care.

CONCLUSION

Utilization of a tourniquet during TKA has minimal impact on postoperative pain scores and opioid consumption when compared with patients who underwent TKA without a tourniquet.

Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism

BACKGROUND

The role of a tourniquet for knee arthroplasty remains controversial. The present Bayesian network meta-analysis investigated the role of various protocols for tourniquet inflation for knee arthroplasty, assessing data on pain control, clinical and functional outcomes, and the rate of deep vein thrombosis (DVT).

MATERIAL AND METHODS

The present Bayesian network meta-analysis was conducted according to the PRISMA guidelines. In March 2021, all clinical trials investigating the role of tourniquet use for knee arthroplasty were considered for inclusion. Groups were divided into those which used a tourniquet in knee arthroplasty procedures versus those which completed the procedure without tourniquet, or with varying protocols of tourniquet use. The hierarchical random-effects model analysis was adopted in all comparisons.

RESULTS

Data from 54 articles (5497 procedures) were retrieved. The absence of tourniquet group evidenced the lowest rate of DVT, and scored the lowest in the visual analogic scale (VAS) at 24-48 h, 1, 3, and 12 months follow-up. The same group evidenced the greatest gain of motion at 3-days, 1 week, 1 month, 3 months, 6 months, and 12 months follow-up, and the highest Knee Society Rating System scores at 1, 3, and 12 months follow-up. Of the outcome data assessed, the straight-leg-raise test was markedly inconsistent: therefore, no recommendations from this test can be made.

CONCLUSION

With regards to the endpoints considered in the present study, knee arthroplasties undertaken without the use of a tourniquet perform better overall.

Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes

INTRODUCTION

The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data.

MATERIAL AND METHODS

The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons.

RESULTS

Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group.

CONCLUSION

For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

The effect of tourniquet uses on total blood loss, early function, and pain after primary total knee arthroplasty: a prospective, randomized controlled trial

Aims

The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid.

Methods

This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events.

Results

The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the length of hospital stay.

Conclusion

Patients who underwent TKA with multiple doses of intravenous tranexamic acid but without a tourniquet presented lower total blood loss and hidden blood loss, and they showed less postoperative inflammation reaction, less muscle damage, lower VAS pain score, and better early knee function. Our results argue for not using a tourniquet during TKA.

Cite this article: Bone Joint Res 2020;9(6):322–332.

Intravenous and subsequent long-term oral tranexamic acid in enhanced-recovery primary total knee arthroplasty without the application of a tourniquet: a randomized placebo-controlled trial

BACKGROUND

To assess the efficacy and safety of intravenous and subsequent long-term oral tranexamic acid (TXA) following total knee arthroplasty (TKA) without a tourniquet.

METHODS

In this double-blinded trial, 118 patients undergoing primary TKA were randomized into two groups: the patients in group A received intravenous TXA at 20-mg/kg 10 min before the surgery and 3 h postoperatively, and then oral 1 g TXA from postoperative day (POD) 1 to POD 14, and the patients in group B received intravenous TXA at 20-mg/kg 10 min before surgery and 3 h postoperatively, and then oral 1 g placebo from postoperative day (POD) 1 to POD 14. The primary outcome was total blood loss. Secondary outcomes included ecchymosis area and morbidity, postoperative transfusion, postoperative laboratory values, postoperative knee function and length of hospital stay. Complications, and patient satisfaction were also recorded.

RESULTS

The mean total blood loss was lower in Group A than in Group B (671.7 ml vs 915.8 ml, P = 0.001). There was no significant difference in the transfusion rate between the two groups. Group A had a higher hemoglobin than Group B on POD 3 (106.0 g/L vs 99.7 g/L, P = 0.001). However, no significant difference was found for Hb or hematocrit on POD 1 or POD 14 between the two groups. Patients in Group A had less ecchymosis morbidity (7 vs 38, P = 0.001), smaller ecchymosis area (1.6 vs 3.0, P = 0.001) than Group B. The blood coagulation level as measured by fibrinolysis (D-Dimer) was lower in Group A than in Group B on POD 1 and POD 3 (4.6 mg/L vs. 8.4 mg/L, respectively, P = 0.001; 1.5 mg/L vs. 3.3 mg/L, respectively, P = 0.001). However, there was no significant difference on POD 14, and the fibrin degradation products showed the same trend. Patients in Group A had less swelling than those in Group B on POD 3 and POD 14. The circumference of the knee was 43.1 cm vs. 46.1 cm (POD 3, P = 0.001) and 41.4 cm vs. 44.9 cm (POD 14, P = 0.001) in Group A vs Group B, respectively. Nevertheless, the circumference of the knee in the two groups was similar on POD 1 and POD 3 M. No significant differences were identified in knee function, pain score, or hospital stay. No significant differences were identified in thromboembolic complications, infection, hematoma, wound healing and patients satisfaction between the two groups.

CONCLUSION

Intravenous and subsequent long-term oral TXA produced less blood loss and less swelling and ecchymosis compared with short-term TXA without increasing the risk of complications.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR-IPR-17012264 ).

Tranexamic acid in primary total knee arthroplasty without tourniquet: a randomized, controlled trial of oral versus intravenous versus topical administration

Abundant literature confirms that intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) reduces blood loss in total knee arthroplasty (TKA). Oral formulations of TXA exhibit profound cost-saving benefits. However, comparisons of the clinical efficacy among three different modalities of TXA administration have not been previously investigated in the setting of TKA with no closed suction drain and tourniquet. A total of 180 patients undergoing TKA were randomized to receive 2-g oral TXA 2 hours preoperatively, 20-mg/kg IV TXA 5 minutes prior to incision, or 2-g IA TXA. The primary outcome was 72-hour blood loss. Secondary outcomes were reductions in hemoglobin, the rate of transfusions, and adverse events. No significant differences were identified with regard to the mean 72-hour blood loss among the three groups (1003 mL in oral group, 1108 mL in IV group, and 1059 mL in IA group, respectively). Similarly, hemoglobin reduction was equivalent among the groups. Only one patient in IV group exhibited deep venous thrombosis. No difference was identified regarding transfusion rates. Oral TXA results in similar blood loss in TKA, with a profound cost-saving benefit, compared with the IA and IV formulations.

Modified Robert Jones bandage can not reduce invisible blood loss after total knee arthroplasty: a randomized-controlled trial

INTRODUCTION

To compare the efficacy and safety of modified Robert Jones bandage (MRJB) and non-compressive dressing (NCD) on reducing invisible blood loss (IBL) after total knee arthroplasty (TKA).

MATERIALS AND METHODS

Eighty patients who underwent unilateral TKA were randomly assigned into two groups: MRJB and NCD groups. Pre- and post-operative hematocrit levels, amount of drained blood and transfused blood were measured and calculated into IBL. Pain score, amount of morphine usage, range of motion (ROM) at discharge, blood transfusion rate, and complications were also recorded and compared between both groups.

RESULTS

There was no significant difference in the mean IBL between MRJB (221.2 ± 233.3 ml) and NCD groups (158.5 ± 186.7 ml) (p = 0.219). Post-operative pain score at rest and during ambulation, amount of morphine usage, ROM at discharge, blood transfusion rate, and complications were also similar between two groups.

CONCLUSIONS

This study cannot determine the benefit of MRJB over NCD. The use of MRJB may not be necessary after primary TKA.

Blood-conserving efficacy of multiple doses of oral tranexamic acid associated with an enhanced-recovery programme in primary total knee arthroplasty: a randomized controlled trial

Aims

The aim of this study was to identify the most effective regimen of multiple doses of oral tranexamic acid (TXA) in achieving maximum reduction of blood loss in total knee arthroplasty (TKA).

Patients and Methods

In this randomized controlled trial, 200 patients were randomized to receive a single dose of 2.0 g of TXA orally two hours preoperatively (group A), a single dose of TXA followed by 1.0 g orally three hours postoperatively (group B), a single dose of TXA followed by 1.0 g three and nine hours postoperatively (group C), or a single dose of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively (group D). All patients followed a routine enhanced-recovery protocol. The primary outcome measure was the total blood loss. Secondary outcome measures were hidden blood loss (HBL), reduction in the level of haemoglobin, the rate of transfusion and adverse events.

Results

Groups C (661.1 ml, sd 262.4) and D (597.7 ml, sd 219.6) had significantly lower mean total blood loss compared with groups A and B. The mean HBL was significantly lower in groups B (699.2 ml), C (533.1 ml) and D (469.9 ml) than in group A (p = 0.006, p < 0.001, and p < 0.001, respectively). Groups C (2.22 ml, sd 0.91) and D (2.04 ml, sd 0.95) had a lower reduction in the level of haemoglobin than groups A and B. However, there were no differences between groups C and D in relation to the three parameters.

Conclusion

The addition of two or three postoperative doses of TXA to one preoperative dose produced a significant reduction in blood loss. The two-dose postoperative regimen is the least necessary regimen for clinical efficacy in primary unilateral TKA. The three-dose regimen produced maximum reduction of blood loss. Cite this article: Bone Joint J 2018;100-B:1025–32.

Comparison of oral versus intra-articular tranexamic acid in enhanced-recovery primary total knee arthroplasty without tourniquet application: a randomized controlled trial

Background

Although randomized controlled trials have confirmed oral tranexamic acid (TXA) can provide similar blood-sparing efficacy compared with intravenous (IV) TXA in total knee arthroplasty (TKA), some concerns do remain about thromboembolic events after such systemic administration. Many studies have confirmed that intra-articular (IA) application of TXA can show similar blood-saving efficacy with minimal levels of systemic absorption compared with IV TXA. However, it remains unclear whether the efficacy and safety of oral TXA administration is equal to or less than that of IA administration in TKA without the use of a tourniquet and drain. Thus, this study was to verify non-inferior efficacy and safety of oral TXA compared with IA TXA in primary TKA.

Methods

A double-blind, randomized, controlled trial was performed to compare three oral doses of TXA (2 g of TXA 2 h before incision, and 1 g of TXA 6 and 12 h after surgery, respectively) with IA TXA (3 g of TXA in 100 mL of saline solution). One hundred forty-seven patients scheduled for TKA were randomized to one of the two interventions. The primary outcome was total blood loss. The secondary outcomes included reduction of hemoglobin concentration, clinical outcomes, blood coagulation values, thromboembolic complications, and transfusion rates.

Results

The mean total blood loss was 788.8 mL in the oral TXA group compared with 872.4 mL in the IA TXA group, with no statistical significance (p > 0.05). There were no significant differences in reduction of hemoglobin level, blood coagulation level, and clinical outcomes. The transfusion rates were 4% in oral group and 5% IA group, respectively. Also, no significant differences were identified in thromboembolic complications.

Conclusion

Oral TXA according to the described protocol demonstrated non-inferiority for primary TKA, with no safety concerns and a greatly reduced cost, compared with the IA TXA. This randomized controlled trial supports the oral administration of TXA in TKA.

Trial registration

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-17010968) dated 23rd March 2017.

The effect of tourniquet usage on cement penetration in total knee arthroplasty: A prospective randomized study of 3 methods

BACKGROUND

It is a randomized study to compare cement penetration on x-rays after total knee arthroplasty (TKA) among 3 different ways to use tourniquets; application during the surgery, application only with implantation prosthesis and with no tourniquet use.

METHODS

A total 69 knees of 59 patients were included in the study in a quasirandom manner. Each patient had physical exams and standard radiographic evaluations at 6 weeks after the TKA procedure. Outcome evaluations included visual analog scale (VAS) scores, Knee Society Scores (KSS), blood transfusion, and drainage status after surgery for all groups. For radiographic review, the tibial plateau was divided into zones in the anterior-posterior and lateral views, according to the Knee Society Scoring System.

RESULTS

The average age of the patients who were eligible for the study was 65.05 (range 46-81) years. All 59 patients included in the study were female patients. Group 1 consisted of 24 patients who had TKA with use of a tourniquet during the entire operation. Group 2 consisted of 20 patients who had TKA with use of tourniquet only at the time of cementing and group 3 consisted of 25 patients with no use tourniquet. There is no significant difference in early cement penetration among the groups (group 1 2.50 mm, group 2 2.28 mm, group 3 2.27 mm; group 1 vs 2 P = .083, group 1 vs 3 P = .091, group 2 vs 3 P = .073). There is no significant difference for postoperative drainage among the 3 groups (group 1 245 mL, group 2 258.76 mL, group 3 175.88 mL; group 1 vs 2 P = .081, group 1 vs 3 P = .072, group 2 vs 3 P = .054). There was no need to transfuse more than 1 unit in any patient. The VAS score was significantly higher (group 1 3.58, group 2 1.55, group 3 1.52; group 1 vs 2 P = .022, group 1 vs 3 P = .018, group 2 vs 3 P = .062) and KSS was significantly lower in the tourniquet group (group 1 63, group 2 79, group 3 82; group 1 vs 2 P = .017, group 1 vs 3 P = .02, group 2 vs 3 P = .082).

CONCLUSION

We do not suggest long-duration tourniquet use, which can lead higher pain scores and reduce functional recovery after total knee arthroplasty.

Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial

BACKGROUND

Tourniquet use during primary total knee arthroplasty is thought to reduce intraoperative blood loss and improve visibility. Our goal was to investigate whether tourniquet use is necessary for controlling intraoperative blood loss when alternatives such as tranexamic acid (TXA) are available.

METHODS

One hundred and fifty patients were equally randomized to 3 groups. Group A was treated with a tourniquet as well as multiple doses of intravenous TXA (20 mg/kg 5 to 10 minutes before the skin incision and 10 mg/kg 3, 6, 12, and 24 hours later) along with 1 g of topical TXA, Group B was treated the same as Group A but without the tourniquet, and Group C was treated with the tourniquet only.

RESULTS

The amount of intraoperative blood loss was similar for the 3 groups. Group B had significantly less hidden blood loss than Group A (p = 0.018) and Group C (p < 0.001). No significant differences (p > 0.05) were observed between Group A and Group B with regard to total blood loss, drainage volume, intraoperative blood loss, transfusion rate, or maximum change in the hemoglobin (Hb) level. We also found significantly more benefits for Group B compared with Groups A and C with regard to postoperative swelling ratio, levels of inflammatory biomarkers, visual analog scale (VAS) pain scores, range of motion at discharge, Hospital for Special Surgery (HSS) score, and patient satisfaction. There were no significant differences (p > 0.05) in the deep venous thrombosis or pulmonary embolus rates among the 3 groups. More wound secretion was observed in the groups in which a tourniquet was used.

CONCLUSIONS

Patients treated with multiple doses of intravenous and topical TXA without a tourniquet had less hidden blood loss, a lower ratio of postoperative knee swelling, less postoperative knee pain, lower levels of inflammatory biomarkers, better early knee function, and even better early satisfaction than those treated with a tourniquet. Long-term follow-up should be performed to evaluate the effects on prosthetic fixation and long-term survival of total knee arthroplasty performed without a tourniquet.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Blood flow restriction training as a prehabilitation concept in total knee arthroplasty: A narrative review about current preoperative interventions and the potential impact of BFR

Osteoarthritis of the knee is one of the most commonly diagnosed joint ailments and responsible for increased rates of total knee arthroplasty surgeries worldwide. Whereas the surgical approach is able to diminish the perceived knee pain of concerned patients', the postoperative recovery is often accompanied by persistent skeletal muscle dysfunctions and atrophy, which is responsible for functional deficits for up to several years. Recent findings indicate that surgery induced adverse effects on skeletal muscles are largely associated with the use of pneumatic tourniquets, wherefore several studies try to reduce tourniquet use in orthopedic surgery. However, due to comparable incidence of muscle impairment and increased surgical challenge, the most frequently applied surgical technique in TKA is still associated with the use of tourniquets. When attenuating TKA induced adverse effects, the preoperative preparation of patients by specific exercises (called prehabilitation) was able to enhance preoperative overall fitness through associated accelerated recovery. Based on patients' limited functional activity, prehabilitation techniques have to be particularly designed to allow regular adherence. The present paper is based on a narrative review of current literature, and provides a novel hypothesis by which blood flow restriction exercises (BFR) are able to improve patients' compliance to prehabilitation. BFR training is characterized by the application of low-resistance exercise with similar intensities as daily living tasks in association with a suppression of venous blood flow in an extremity, achieving significant morphological and neuromuscular adaptations in skeletal muscles. In addition, preoperative enhancements in muscle health with corresponding benefits in overall fitness, BFR induced molecular alterations could also be able to interfere with TKA induced pathological signaling. Therefore, based on the known major impact of BFR on skeletal muscle physiology, the present paper aims to illustrate the potential beneficial impact of BFR training as a prehabilitation concept to promote patients regular adherence to preoperative exercises and thus achieve an accelerated recovery and increases in patients' satisfaction.

After early release of tourniquet in total knee arthroplasty, should it be reinflated or kept deflated? A randomized trial

PURPOSE

This study was undertaken to determine the efficacy of reinflation of the tourniquet after its early release in TKA compared to early release alone, in terms of surgical field visualization and operative time. We also questioned whether tourniquet reinflation after its early release is safe, with respect to post-operative blood loss, post-operative pain and other tourniquet-related complications.

METHODS

Two hundred and six patients undergoing TKA were randomly allocated to either the early release (deflation) group (n = 105) or reinflation after early release (reinflation) group (n = 101). Efficacy was measured in terms of surgical field visualization, specifically the number of wound clearances, and operative time. Safety outcomes were drained volume, decline in haemoglobin on post-operative days 2 and 5, the frequency of transfusion, knee and thigh pain visual analog scale, local wound complications, tourniquet site complications and other complications, including infection, deep vein thrombosis and pulmonary embolism.

RESULTS

Surgical field visualization was better in the reinflation group; however, the operative time did not differ between the two groups. There were no differences between the two groups in post-operative blood loss, decline in haemoglobin on days 2 and 5, transfusion rate, pain level, local complications and other complications.

CONCLUSION

Reinflation of tourniquet is a safe alternative to its early release after deflation in that it improves surgical field visualization during TKA.

LEVEL OF EVIDENCE

Therapeutic study, Level I.

Efficacy and safety of a new elastic tourniquet cuff in total knee arthroplasty: a prospective randomized controlled study

Background

The effects of cuff shape, timing of tourniquet application, and automated systems using limb occlusion pressure (LOP) have been reported to minimize the appropriate tourniquet pressure. However, studies on the raw material of the cuff itself to reduce the complications related to the tourniquet have been very rarely reported. The purpose of this study is to report the efficacy and safety of a tourniquet system with a new elastic cuff in which pressure is set with LOP in total knee arthroplasty (TKA).

Methods

A total of 63 patients who underwent primary TKA for osteoarthritis were enrolled from July to December 2015. Thirty-one patients were allocated to the new elastic cuff group and 32 in the conventional cuff group. Bloodless surgical field, pain visual analog scale (VAS) on the thigh, thigh circumference, range of motion, incidence of deep vein thrombosis, and muscle enzyme level after surgery were checked and compared between the 2 groups.

Results

Only 1 of the 31 patients in the elastic cuff group required more pressure for obtaining a bloodless surgical field, whereas 4 of the 32 patients in the conventional cuff group required more pressure to complete surgery without being disturbed by sustained bleeding. Two patients in the conventional cuff group needed treatment for blisters and bullae at the tourniquet application site. There was no difference in pain VAS score, thigh circumference, range of motion, incidence of deep vein thrombosis, and level of muscle enzyme.

Conclusions

A new elastic tourniquet cuff provided a more proper bloodless surgical field with less adjustment of tourniquet pressure despite a similar level of tourniquet pressure compared to the conventional cuff and had a low incidence of skin complications on the site of tourniquet application in TKA. These benefits make it an effective and safe medical device for orthopedic surgery requiring a tourniquet, such as TKA.

Soft-tissue damage during total knee arthroplasty: Focus on tourniquet-induced metabolic and ionic muscle impairment

PURPOSE

Advantages of tourniquet use in TKA include benefits for surgeons and patients, varying from a bloodless operation site to a reduced intervention time. The time under ischemia and the reperfusion period are crucial phases for affected soft-tissue, most commonly the extensor mechanism.

CASE REPORTS

documented its impact on soft-tissue, ranging from necrotic muscle damage to systemic inflammation. Recently, research regarding tourniquet application patterns discuss clinical outcome parameters in the context of soft-tissue damage, excluding the underlying pathophysiological mechanisms.

METHODS

This review summarizes the molecular aspects of soft-tissue damage occurring during tourniquet application in TKA with special focus on ischemia/reperfusion injury. Recent meta-analyses and original trials were reviewed for data on muscle damage and are presented.

CONCLUSION

Although underlying pathomechanisms are well known and presented, clinical orthopedic research has so far not addressed this issue. In context of physical training, positive effects regarding postoperative recovery might be possible if more attention is paid to prepare involved muscle preoperatively to TKA (prehabilitation).

Tourniquet and closed-suction drains in total knee arthroplasty. No beneficial effects on bleeding management and knee function at a higher cost

BACKGROUND

Blood loss is a major concern in total knee arthroplasty (TKA) along with postoperative knee function. The present study explores the impact of tourniquet (T) and closed-suction drains (D) on these parameters in TKA.

MATERIALS AND METHODS

A prospective study was conducted on 111 patients admitted for TKA. Subjects were divided into three groups: 36 in group T+D+, 42 in T-D+ and 33 in T-D- (where T+: prolonged tourniquet use, T-: cementation-only tourniquet, D+: closed-suction drain use, and D-: no drain).

RESULTS

No statistically significant differences were observed among the three groups(T+D+, T-D+ and T-D-) for total blood loss, hemoglobin levels over the first six postoperative weeks and blood transfusion rate. Intraoperative bleeding was significantly reduced in T+ subjects compared to T- subjects (100±88mL vs. 279±235mL respectively, P<0.001), yet length of surgery was unaffected. Hidden blood loss was lower in D+ subjects compared to D- subjects (1161±554mL vs. 1667±554mL respectively, P<0.001), but was offset by the blood loss in the drains. Early postoperative range of motion (ROM) was superior in group T-D- compared to group T+D+. Nevertheless, postoperative week 6 ROM was similar between the 3 groups as was patient-reported postoperative pain. A patient with a drain represents 35min of extra nursing time and a total cost of $31.87 CAD.

CONCLUSIONS

Whole-course tourniquet and closed-suction drain use in TKA do not yield beneficial results while increasing costs. Their use is therefore deemed unnecessary.

LEVEL OF EVIDENCE

III (case control prospective study).

Timing of tourniquet release in total knee arthroplasty: A meta-analysis

BACKGROUND

For total knee arthroplasty (TKA), the tourniquet is routinely employed for better visualization, less blood loss, and easier cementation. However, the time to release tourniquet remains controversial. Therefore, we performed current meta-analysis to assess whether releasing tourniquet before wound closure is more effective in reducing blood loss than releasing tourniquet after wound closure in TKA without an increased risk of complications.

METHODS

To conduct this meta-analysis, we searched Medline, Embase, Web of science, and the Cochrane library up to November 2016, for randomized controlled trials comparing tourniquet releasing before and after wound closure in TKA. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Methodological quality of the trials was assessed using the Cochrane risk assessment scale. The data of the included studies were analyzed using Stata 12.0.

RESULTS

Sixteen trials involving 1010 patients were identified in current meta-analysis. Our meta-analysis demonstrated that there were no significant differences in the 2 groups in terms of calculated blood loss (weighted mean difference [WMD] = 160.65, 95% confidence interval [CI]: -0.2 to 321.49, P = .05), postoperative blood loss (WMD = -45.41, 95% CI: -120.11 to 29.29, P = .233),postoperative hemoglobin decline (WMD = 0.16, 95% CI: -2.5 to 2.82, P = .905), transfusion volume (WMD = 79.19, 95% CI: -5.05 to 163.44, P = .065),transfusion rates (relative risk [RR] = 1.19, 95% CI: 0.95-1.50, P = .134), major complications (RR = 0.51, 95% CI: 0.15-1.73, P = .278), and deep vein thrombosis (RR = 0.44, 95% CI: 0.14-1.37, P = .157).Compared with the group of releasing tourniquet after wound closure, the group of releasing tourniquet before wound closure had a higher volume of total blood loss (WMD = 130.96, 95% CI: 58.83-203.09, P = .000) and a longer operation time (WMD = 6.56, 95% CI: 3.12-10.01, P = .000). However, releasing tourniquet before wound closure could reduce minor complications (RR = 0.53, 95% CI: 0.34-0.82, P = .004).

CONCLUSIONS

On the basis of current meta-analysis, the method of releasing tourniquet before wound closure could increase total blood loss and operation time; nevertheless, the risk of complications decreased. Thus, if patients are in severe anemia condition, the tourniquet perhaps should be released after wound closure to decrease blood loss. In contrary, releasing tourniquet before wound closure to decrease the risk of complications would be a better choice.

Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: An updated meta-analysis

BACKGROUND

The appropriate route for administering tranexamic acid in primary total hip (THA) and knee arthroplasty (TKA) remains controversial. The purpose of this meta-analysis was to compare the efficacy and safety of topical or intravenous tranexamic acid.

METHODS

PubMed, EMBASE, and the Cochrane Library databases were systematically searched for randomized controlled trials (RCTs) comparing topical and intravenous tranexamic acid following primary THA or TKA. Primary outcomes were transfusion frequency and maximum drop in hemoglobin. Other parameters included total blood loss (TBL), hidden blood loss, drainage volume, hemoglobin level on postoperative day 1 (POD 1), deep vein thrombosis (DVT), pulmonary embolism (PE), wound complications and other adverse events. Data were analyzed using Rev Man 5.2.

RESULTS

A total of 18 RCTs involving TKA and 4 RCTs involving THA, corresponding to approximately 2260 patients, were included in the meta-analysis. No significant difference between topical and intravenous tranexamic acid was found in transfusion requirement (RR 1.14, 95%CI 0.87 to 1.50, p=0.35). The maximum drop in hemoglobin was significantly smaller in the intravenous group than in the topical group (MD 0.33g/dL, 95%CI 0.07 to 0.58, p=0.01); similar results were observed for the subset of studies involving THA (MD 0.49g/dL, 95%CI 0.28 to 0.70, p<0.001) and the subset involving TKA (MD 0.30g/dL, 95%CI 0.02 to 0.59, p=0.04). The topical and intravenous groups did not differ significantly in TBL, drainage volume, hemoglobin level on POD 1, DVT, PE, wound complications or other adverse events.

CONCLUSION

The available evidence indicates similar transfusion requirements and safety for topical and intravenous tranexamic acid in THA and TKA. However, intravenous injection seems to be associated with a smaller maximum drop in hemoglobin.

The effect of tourniquet and knee position during wound closure after total knee arthroplasty on early recovery of range of motion: a prospective, randomized study

INTRODUCTION

There is no consensus on the position of the knee joint while performing wound closure after total knee arthroplasty (TKA). Further, there are no studies focusing on the association between early functional outcomes and different wound closure strategies. Therefore, we investigated the effects of tourniquet and knee position during wound closure on early recovery of range of motion (ROM) after primary TKA. To our knowledge, this is the first study to evaluate the influence of both tourniquet and knee position during wound closure in primary TKA.

METHODS

One hundred-twenty eligible patients were consecutively enrolled in this study and randomly divided into four groups according to wound closure strategy. Wound closure was either performed with the knee in flexion at 90° or in full extension, with the combination of an inflated or deflated tourniquet. Visual analogue score (VAS), knee ROM, ROM recovery, knee society score (KSS), and wound complications were evaluated in the early postoperative period.

RESULTS

After the first postoperative week, ROM recovery in the group with knee in extension and inflated tourniquet was significantly lesser than the two groups with deflated tourniquets. Between the first and fourth postoperative weeks, ROM recovery in the group with knee inflection and deflated tourniquet was significantly higher than the two groups with knee in extension. After the first postoperative week, the visual analog score (VAS) for pain in the group with knee inflection and deflated tourniquet was significantly lesser than the two groups with inflated tourniquets. The differences in the outcomes between the four groups were not significant after the fourth postoperative week. The incidence of wound complications and KSS were not significantly different between the four groups.

CONCLUSION

Following TKA, wound closure with the knee in flexion and after deflating the tourniquet significantly decreased postoperative pain and promoted the recovery of ROM in the early postoperative period.

Multiple Boluses of Intravenous Tranexamic Acid to Reduce Hidden Blood Loss After Primary Total Knee Arthroplasty Without Tourniquet: A Randomized Clinical Trial

BACKGROUND

The optimal dosage and timing of tranexamic acid (TXA) in total knee arthroplasty (TKA) are undetermined. The purpose of this study was to explore the effect of multiple boluses of intravenous TXA on hidden blood loss (HBL), inflammatory response, and knee function after primary TKA without tourniquet.

METHODS

A total of 151 patients were randomly divided into 3 groups to receive single bolus of 20 mg/kg IV-TXA before skin incision (group A), or another bolus of 10 mg/kg IV-TXA 3 hours later (group B), or another 2 boluses of 10 mg/kg IV-TXA 3 hours and 6 hours later (group C). TKAs without tourniquet were operated by 1 single surgeon. The primary outcomes were HBL and maximum hemoglobin drop. Other outcome measurements such as total blood loss, transfusion rate, inflammation markers (C-reactive protein, interleukin 6), visual analog scale pain score, limb swelling ratio, Hospital for Surgery Score, range of motion, length of hospital stay (LOH), and deep venous thrombosis were also compared.

RESULTS

The mean HBL and maximum Hb drop in group C (467.6 ± 305.9 and 20.9 ± 9.3) was lower than those in group A (763.0 ± 373.3, P < .001; 28.7 ± 12.2, P < .001) and group B (637.5 ± 303.5, P = .010; 25.2 ± 8.4, P = .036). However, such differences were not detected between groups A and B (P = .058 and P = .080, respectively). The mean value of total blood loss in the groups A, B, and C were 967.2 ± 380.1, 803.7 ± 321.8, and 677.6 ± 326.0 mL, respectively, with a significant intergroup difference (P < .001). The mean serum level of C-reactive protein and interleukin 6 in group C were lower than those in group A and group B on postoperative days 1 and 2. The visual analog scale pain score and swelling ratio were also lower in group C than in the other 2 groups with statistical significance on POD 1-3. Moreover, the Hospital for Surgery Score, range of motion, and LOH were better in group C. No episodes of transfusion or deep venous thrombosis had occurred.

CONCLUSION

Multiple boluses of IV-TXA can effectively reduce HBL after primary TKA without tourniquet. What is the most important is that, by adding another bolus of IV-TXA, patients can gain a smaller decline of Hb, less postoperative inflammatory response, less pain, less knee swelling, better knee function, and shorter LOH.

Strategies for reducing peri-operative blood loss in total knee arthroplasty

During the last ten years, greater attention has been given to the management of peri-operative blood loss after total knee arthroplasty (TKA), as it is a modifiable outcome that has a significant effect on the rate of complications, the recovery, and the economic burden. Blood loss after TKA has been greatly reduced during this time, thereby dramatically reducing the rates of allogeneic transfusion. This has significantly reduced the complications associated with transfusion, such as fluid overload, infection, and increased length of stay. The greatest advent in lowering peri-operative blood loss after TKA has been the introduction of tranexamic acid, which reduces blood loss without increasing the risk of thromboembolic events. This paper discusses the ways of reducing blood loss after TKA, for which a multimodal algorithm, with pre-, intra- and post-operative measures, has been adopted at our institution.

Is postoperative cell salvage necessary in total hip or knee replacement? A meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this study was to determine whether there are hematological or clinical differences with the use of postoperative cell salvage after total knee (TKR) and hip replacement (THR).

METHODS

A systematic literature review based on PubMed, EMBASE, the Cochrane Library Database in any language regarding postoperative cell salvage following TKR or THR was performed. High quality of randomized controlled trials were identified. The data was analyzed using Rev Man 5.2.

RESULTS

19 randomized controlled trials (12 in TKR, 4 in THR and 3 in both) about 3482 patients were identified and included in this meta-analysis. Postoperative cell salvage significantly reduced the allogeneic blood transfusion requirement after TKR (RR = 0.46, 95% CI = 0.30 to 0.72) and THR (RR = 0.46, 95%CI = 0.32 to 0.68). It also demonstrated a higher level of postoperative Hemoglobin (MD = 0.26 g/dL, 95%CI = 0.15 to 0.37) with the use of postoperative cell salvage. No significant differences were detected regarding length of hospital stay, the incidence of febrile reaction, wound infection and deep vein thrombosis.

CONCLUSION

The results strengthen the fact that postoperative cell salvage is effective and safe to reduce the rate of transfusion after TKR and THR. As the relatively poor methodological quality and heterogeneity, further research is needed to confirm its safety and cost-effectiveness.

General anesthesia: to catheterize or not? A prospective randomized controlled study of patients undergoing total knee arthroplasty

This study was to investigate whether urinary catheterization could be avoided for patients undergoing total knee arthroplasty (TKA) under general anesthesia with saphenous nerve block. 314 patients from a single surgical team were randomized to receive either an indwelling urinary catheter or no urinary catheter before the surgery. The results revealed that the prevalence of postoperative urinary retention (POUR) was quite low in both groups (5.7% vs 6.4%, P=1). Additionally, the prevalence of urinary tract infection was significantly higher in patients using an indwelling catheter (5.1% vs 0.6%, P=0.036). We also identified age, male gender, ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and duration of surgery as the risk factors for POUR in these patients.

Releasing of tourniquet before wound closure or not in total knee arthroplasty: a meta-analysis of randomized controlled trials

The purpose of this study is to examine our hypothesis that releasing tourniquet intraoperatively before wound closure is better than releasing postoperatively after wound closure and bandaging. We carried out a systematic review using meta-analysis of selected randomized controlled trials comparing tourniquet releasing before and after wound closure in TKA. The results showed that tourniquet releasing before wound closure significantly increased the total blood loss (P<0.00001), calculated blood loss (P<0.0001) as well as postoperative blood loss (P=0.007). However, it decreased the risk of both minor (P=0.0007) and major complications (P=0.05). The available evidence indicated that releasing tourniquet before wound closure for hemostasis increased perioperative blood loss, nevertheless, the risk of complications decreased significantly.

Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The aim of this study is to evaluate the effects of tourniquet release before wound closure for hemostasis or after wound closure in cemented total knee arthroplasty (TKA).

METHODS

We conducted a meta-analysis and review work on relevant clinical outcomes to evaluate the effects of the timing of tourniquet release in cemented TKA. Electronic databases were searched for relevant randomized controlled trials (RCTs) that compared outcomes of tourniquet release before wound closure for hemostasis with tourniquet release after wound closure. The methodological quality of each included RCT was assessed in terms of the 12-item scale. The meta-analysis was performed with STATA 12.0 software.

RESULTS

Eleven RCTs involving 651 patients with 670 TKAs were included in this meta-analysis. Of these, 332 patients (342 knees) were in an early tourniquet release group and 319 patients (328 knees) in the late tourniquet release group. The results showed that there were no significant differences in overt blood loss, hemoglobin drop, and blood transfusions, whereas the tourniquet release after wound closure might increase the risks of overall complications and major complications.

CONCLUSIONS

Tourniquet release before wound closure for hemostasis might reduce the rate of complications, but it could not limit overall blood loss. The current evidences are not enough to indicate that tourniquet release before wound closure is superior to its release after wound closure in cemented TKA.

Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial

This study was aimed to determine the efficacy and safety of combined intravenous (IV) and topical application of tranexamic acid (TXA) in unilateral total knee arthroplasty (TKA) compared with the IV-TXA. One hundred eight-four patients were enrolled. Participants received either 3g of IV-TXA or 1.5g topical TXA combined with 1.5g IV-TXA. The results revealed that compared with the 3g IV-TXA, adding 1.5g topical TXA to 1.5g IV-TXA in unilateral TKA can have the similar effectiveness in reducing transfusion rate and total blood loss without sacrificing safety. The most important is that by adding topical TXA, patients can gain a smaller maximum decline of hemoglobin (Hb), less drainage volume, less postoperative knee pain, less knee swelling, shorter length of hospital stays and higher short-term satisfaction.