A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

Are tourniquets indicated in total knee arthroplasty in the era of tranexamic acid: A meta-analysis and systematic review

Introduction

There is conflicting evidence in the literature regarding the clinical utility of tourniquets in total knee arthroplasty (TKA), specifically in regards to perioperative blood loss. In this meta-analysis and systematic review, we aim to evaluate the clinical advantages and disadvantages associated with tourniquet use in the setting of TKA.

Methods

A systematic review was conducted through April 2017 using keywords: "tourniquet" and "total knee arthroplasty" or "total knee replacement". Perioperative variables including TXA use, blood loss, incidence of venous thromboembolism (VTE), and wound complications were either extracted from the studies or corresponding authors were contacted. A sub-analysis was conducted to evaluate the effects of TXA on intraoperative and total blood loss (TBL), and VTE incidence.

Results

After review of 558 articles, 19 studies reporting outcomes in 1094 patients were analyzed. Intraoperative blood loss was significantly lower in the tourniquet cohorts compared to non-tourniquet (p < 0.01). TBL was reduced in tourniquet groups but not significantly (p = 0.08). In contrast, calculated blood loss was greater in tourniquet groups, but this difference was not significant (p = 0.43). There was a greater likelihood for wound complications and VTE among tourniquet assisted TKA, albeit only significant for the former (p = 0.01). TXA sub-analysis demonstrated intraoperative blood loss was significantly reduced with tourniquet use regardless of TXA implementation (p < 0.01). In studies without TXA, tourniquet patients were at greater risk of developing VTE (p = 0.08). These risks decreased with TXA administration.

Conclusion

This meta-analysis demonstrates that tourniquets prevent intraoperative blood loss, yet within the postoperative period, there is no significant difference in TBL between tourniquet and non-tourniquet assisted TKA.

Level of evidence

Level II; Systematic Review and Meta-Analysis.

Effect of needle types and diameters using in spinal anesthesia on optic nerve sheath diameter: Prospective randomized study

BACKGROUND

This prospective randomized study aimed to investigate the impact of needle types and diameters used in spinal anesthesia (SA) on optic nerve sheath diameter (ONSD) in patients undergoing lower extremity orthopedic surgery.

METHODS

Patients were randomly assigned to 3 groups based on the needle type and size used for SA: Group 25w (25 gauge Whitacre needle), Group 27q (27 gauge Quincke needle), and Group 25q (25 gauge Quincke needle). Initially, 165 patients (55 in each group) were enrolled, with 146 patients ultimately included in the analysis (Group 25w, n = 49; Group 27q, n = 48; Group 25q, n = 49). ONSD measurements were conducted using ultrasound guidance at 5 time points: T0 (pre-SA), T1 (5 minutes post-SA), T2 (5 minutes post-tourniquet inflation), T3 (5 minutes post-tourniquet deflation), and T4 (24 hours post-operation). Additionally, oxygen saturation, systolic arterial pressure, mean arterial pressure, diastolic arterial pressure, and heart rate were recorded at these time points.

RESULTS

Analysis of ONSD measurements revealed no significant differences among the groups at time points T0,T1,T2, and T4 (P = .7293, P = .4428, P = .3676, and P = .3667, respectively). However, at T3, ONSD values were significantly higher in Group 27q compared to Group 25q (P = .0325). Across all groups, the mean ONSD values measured post-tourniquet release (T3) were higher than those at T0,T2, and T4 (P < .001 for all). The incidence of nausea was similar among the groups, and no cases of headache or visual impairment were reported within the initial 24 hours post-surgery.

CONCLUSION

In conclusion, our study suggests that while subarachnoid injection and tourniquet inflation do not impact intracranial pressure (ICP), tourniquet deflation leads to an increase in ICP during lower limb surgery under SA. Therefore, caution should be exercised when using a tourniquet in patients at risk of elevated ICP.

Treating Osteoarthritis in Jehovah's Witness Patients

This article addresses the challenges surrounding hip and knee osteoarthritis (OA) treatment in Jehovah's Witnesses (JWs), focusing on the complexities arising from their refusal of blood products and transfusions. Acknowledging the heightened risk of blood loss anemia during joint replacement surgery, this review explores documented strategies that enable safe elective joint arthroplasty in JW patients, emphasizing comparable initial diagnostic methods and non-operative treatments up until the pre-operative stage. Special considerations should be taken in the perioperative and intraoperative stage. Despite these challenges, safe arthroplasty is feasible with satisfactory outcomes through a combination of careful preoperative optimization, blood saving protocols, and cultural sensitivity.

Summary of the best evidence for the safe use of pneumatic tourniquet in limb surgery

PURPOSE

To retrieve, evaluate, and summarize the best available evidence regarding the safe use of pneumatic tourniquet in patients undergoing Limb surgery, providing guidance for preoperative assessment, operation methods and precautions, complication prevention and treatment in clinical practice.

METHODS

Using the PIPOST tool, we formulated an evidence-based question, conducted searches in relevant Chinese and international databases and websites for clinical decisions, guidelines, evidence summaries, systematic reviews, and expert consensus on the use of limb surgical tourniquets. The search was limited to literature published until September 30, 2023. Quality assessment and evidence extraction were performed on eligible documents.

RESULTS

This study included a total of 13 articles, including 2 clinical decision-making articles, 3 guidelines, 5 expert consensus articles, 1 standard and 2 systematic reviews. A total of 34 best pieces of evidence recommendations were summarized across 10 aspects, including indications and contraindications for the use of pneumatic tourniquets, preoperative evaluation of operators, selection and placement of tourniquet cuffs, tourniquet inflation, monitoring during inflation, tourniquet deflation, common complications and prevention, equipment safety, documentation, and training and education.

CONCLUSION

The best evidence summarized in this study can provide reference for clinical medical staff to safely use pneumatic tourniquets, but in clinical practice, targeted selection and application of evidence should be combined with specific situations to improve the safety and hemostatic effect of pneumatic tourniquet use.

Role of tourniquet release timing on blood loss and functional outcomes in total knee arthroplasty: Insights from a low- and middle-income country

Purpose

To identify the effect of releasing a tourniquet before versus after wound closure in total knee arthroplasty (TKA) on blood loss, functional outcome and postoperative complications.

Methodology

A prospective cohort study was conducted including 53 patients from May 2023 to September 2023. All patients underwent unilateral TKA and were divided into two groups based on surgeon preference of deflating tourniquet, Group A consisted of patients in whom the tourniquet was deflated before wound closure for haemostasis and Group B consisted of patients in which tourniquet was deflated after wound closure and compressive dressing. Blood loss was evaluated via intraoperative blood loss (the number of soaked sponges/gauzes, blood in a suction bottle, total output in a suction bottle-irrigation used) and on-field blood loss and calculated blood loss (Using Gross and Meunier's formula). The Functional outcome was evaluated using Knee injury and osteoarthritis score-42 questions. Early postoperative complications and differences in the requirement of blood transfusions were also assessed.

Results

There was a significant difference in intraoperative blood loss between the two groups. The median intraoperative blood loss was 135 mL (interquartile range [IQR]: 90-149) in Group A and 56.2 mL (IQR: 45-68) in Group B (p value: 0.001). However, no difference was found between the groups in calculated blood loss using Gross and Meunier's formula. The median calculated blood loss was 439 mL (IQR: 450-813) in Group A and 508 mL (IQR: 226-671) in group B (p value: 0.981). There was no significant difference between the groups in blood transfusion requirements or functional outcomes.

Conclusion

Based on our results, we conclude that the intraoperative blood loss in TKA is significantly different between the groups but only represents a fraction of true blood loss (23%). The timing of releasing the tourniquet does not affect functional outcomes, blood transfusion and postoperative morbidity; hence, any time can be opted as per surgeon preference.

Level of Evidence

Level II, prospective comparative study.

Methodological Assessment of the 100 Most-Cited Articles in Total Knee Arthroplasty in the Last Decade Compared to the All-Time List

BACKGROUND

Recent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence.

METHODS

The top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published).

RESULTS

The largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05).

CONCLUSIONS

Our findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making.

Randomized Controlled Trial of Irrigation-Coupled Bipolar Electrocautery Versus Tourniquet in Total Knee Arthroplasty

Background

Recovery from total knee arthroplasty remains arduous for some patients, prompting interest in perioperative management. While tourniquet use is not associated with longer-term outcomes, its effect on quadriceps strength in the immediate postoperative window is unknown.

Methods

A single-center, double-blind, randomized controlled trial of 66 patients undergoing primary total knee arthroplasty from 2019 to 2022 was performed to compare the use of an irrigation-coupled bipolar device (ICBD) and no tourniquet (ICBD group, N = 34) to tourniquet use with no ICBD (tourniquet group, N = 32). Groups were similar with respect to age, sex, and obesity. The primary outcome was quadriceps strength at 2 weeks, measured using a handheld dynamometer and standardized to the contralateral side. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was measured with the difference from baseline serving as a secondary outcome. Comparisons were performed using the Student's t-test.

Results

Only 28 patients, 14 in each group, had primary outcome data. At 2-weeks, quadriceps strength was higher in the ICBD group compared to the tourniquet group (83% vs 70%), though not statistically significant (P = .16). There was no difference between the ICBD and tourniquet groups in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement changed at 2-weeks (13 vs 10, P = .37) or 6-weeks (16 vs 17, P = .76).

Conclusions

Tourniquet use was associated with a small but not statistically significant difference in quadriceps strength at 2 weeks that may justify further study given the loss of power here. There can be limitations to conducting randomized controlled trials that are important for early-career investigators to consider and that were magnified due to COVID-related restrictions in the present study, which we discuss.

Level of Evidence

Level II.

Impact of tourniquet use in total knee arthroplasty on functional recovery and postoperative pain: a prospective study

BACKGROUND

Tourniquet use during total knee arthroplasty (TKA) remains controversial. The purpose of this study is to determine the impact of tourniquet use only during cementation compared with its use throughout the entire surgery concerning early outcomes in functional recovery, pain, quadriceps function, and rehabilitation.

METHODS

Between November 2019 and March 2020, 118 patients were enrolled in this study, with 59 patients undergoing TKA with a tourniquet during the entire surgery (group 1) and 59 patients with a tourniquet only during cementation (group 2). Twenty-eight patients were unable to complete follow-up leaving fifty in group 1 and forty in group 2. Primary endpoints were surgical time, postoperative knee and thigh pain, and functional recovery. Secondary endpoints were 6-month clinical scores and blood loss.

RESULTS

Patients in group 1 had statistically significantly increased knee pain on postoperative day 3 (p = 0.004), and thigh pain on postoperative day 1 (p < 0.001), 2 (p < 0.001), and 3 (p = 0.027), and longer time intervals to achieve straight leg raise maneuver (p = 0.006) compared to group 2. However, it did not affect overall narcotic consumption, knee pain (day 1-2), functional recovery, ROM, ability to do the first walk, Oxford knee score, length of stay, and complication rate. There was no statistically significant difference in terms of 6-month postoperative knee score, surgical time, and blood loss between the two groups.

CONCLUSION

Tourniquet use diminishes quadriceps function and increases postoperative thigh pain and, to a lesser extent, knee pain. We, therefore, recommend the use of a tourniquet only during cementing.

LEVEL OF EVIDENCE

1; prospective randomized study.

Drainage in primary and revision hip and knee arthroplasty

Drainage after total hip or knee arthroplasty (THA, TKA) used to be systematic to prevent complications and notably hematoma and infection. However, improvement in practices, the introduction of blood-sparing protocols and above all the conclusions reported in many studies have cast doubt on this dogma. There is abundant literature on the pros and cons of drainage after primary THA and TKA. The main endpoints were transfusion rates and volumes, total blood loss and variations in hemoglobin levels. Clinical endpoints comprised pain, edema, postoperative hematoma and, more rarely, short-to-medium-term function. Except for a few studies reporting greater pain and edema without drainage, there is agreement that drainage not only provides no benefit but actually aggravates postoperative bleeding. There are fewer studies of drainage in revision procedures for the hip and very few for the knee. The interest of drainage has not been demonstrated and again postoperative bleeding is aggravated. Whether in primary or revision arthroplasty, tranexamic acid is recommended when not contraindicated, whatever the administration protocol. However, it should not be seen as the sole and determining reason for abandoning drainage. LEVEL OF EVIDENCE: V, expert opinion.

The Effect of Tranexamic Acid With or Without Tourniquet on Blood Loss in Total Knee Arthroplasty at a Community Hospital

Tourniquets have long been used in total knee arthroplasty due to the theoretical improvement of bleeding control, integration of cement-bone interface, visibility, and efficiency of the overall surgery. However, this has become increasingly disputed. Comparative studies in total knee arthroplasty employing chemical prophylaxis, i.e., tranexamic acid, have been conducted. This retrospective cohort study evaluated the effect of tranexamic with or without a tourniquet on mean blood loss, hemoglobin, and length of stay in total knee arthroplasty patients. A total of 153 patients' records met the inclusion criteria, 95 patients (62%) were in the tranexamic acid-only group while 58 patients (38%) were in the tranexamic acid plus tourniquet group. Based on mean blood loss in mL (827.5 without vs. 810.1 with the tourniquet, p=0.805), hemoglobin counts in g/dL (12.6 without vs. 12.5 with the tourniquet, p=0.598), and length of stay in days (1.0 days without vs. 1.1 with the tourniquet, p=0.204), there was no statistical difference between the tranexamic alone vs. tranexamic plus tourniquet groups. There were no statistical differences in the mean BMI between groups (32.3 without vs. 32.4 with tourniquets, p=0.901). The patient population had more women (64.1%) than men (35.9%) (p=0.001), but no significant difference in gender based on tourniquet use (p=0.521). The tourniquet group averaged three years younger than the tranexamic alone group (age mean 68.2 without vs 65.3 with tranexamic, p=0.029). This study found no identifiable difference in the three observed variables, indicating that tourniquet provides limited to no additional benefit in reducing blood loss over tranexamic alone in total knee arthroplasty, while tranexamic alone has no deleterious decrease in mean hemoglobin or increase in length of stay.

The temporal effects of variable tourniquet use on pain after total knee arthroplasty

BACKGROUND

Tourniquet use in total knee arthroplasty (TKA) remains controversial. While widely studied, any temporal effects on pain and opioid utilization have not been investigated. We hypothesized that postoperative opioid utilization increases with increasing tourniquet times in TKA.

METHODS

We retrospectively reviewed 1110 TKAs by three arthroplasty surgeons from October 2016 through September 2019. Exclusion criteria included ambulatory surgery, undocumented tourniquet times, simultaneous bilateral TKA, and diagnoses other than osteoarthritis, inflammatory arthritis, or osteonecrosis. Postoperative opioid medications were converted to daily morphine milligram equivalents (MME/day). Secondary outcomes included range of motion (ROM) at 1-month, 3-month, and 1-year visits as well as patient reported outcomes measures (PROMs) at 3 and 12 months.

RESULTS

Nine-hundred and eleven patients were included and stratified based on tourniquet use. Three-hundred and four patients were assigned to a "No Use" group (≤10'); 138 patients to "Low Use" (11-60'); 177 patients to "Medium Use" (61-90'); and 292 patients to "Prolonged Use" (91-120). Compared to No Use, MME/day was significantly increased with Medium Use (+7.676 MME/day, p = 0.001) and Prolonged Use (+12.44 MME/day, p =< 0.001). No significant differences were found between No Use and Low Use groups. Estimated blood loss (EBL) in Low Use and No Use groups was significantly increased compared to other groups (+120 mL, p < 0.001, +109 mL, p < 0.001 respectively). Post-operative ROM and complication rates were similar between groups at 1 year post-TKA.

CONCLUSIONS

A threshold of 60 min of tourniquet time is associated with increased MME/day postoperatively compared to No Tourniquet. Functional and patient-reported outcomes are comparable between groups at 1 year follow-up.

With or without a Tourniquet? A Comparative Study on Total Knee Replacement Surgery in Patients without Comorbidities

Background and Objectives: This study aimed to determine the effects of tourniquet use and the complications of total knee arthroplasty (TKA) in patients without comorbidities to investigate whether tourniquet application can be employed without adverse effects and to assess its impact on the occurrence of any complications. Materials and Methods: A total of 106 patients who underwent unilateral TKA were divided randomly into two groups according to whether a tourniquet was used during the surgery or not. Patients with comorbidities (except arterial hypertension) were excluded from the study. Knee Injury and Osteoarthritis Outcome Score, joint range of motion, visual analog scale (VAS) score, total blood loss during and after surgery, postoperative analgesic consumption, and side effects were the main factors evaluated in the study. Results: In the tourniquet group, where the VAS scores were higher, the use of analgesics was also significantly higher. While there was no statistically significant difference in total blood loss between the tourniquet and non-tourniquet groups, the postoperative and occult blood losses were higher in the tourniquet group. The differences between the two groups in all other parameters were very small and not statistically significant. Conclusions: The findings of the current study suggest that when the comorbidities of patients are thoroughly documented and clarified prior to surgery, tourniquets should be applied selectively to individuals without any pre-existing health conditions.

Tourniquet use benefits to reduce intraoperative blood loss in patients receiving total knee arthroplasty for osteoarthritis: An updated meta-analysis with trial sequential analysis

PURPOSE

The efficacy and safety of tourniquets use during total knee arthroplasty (TKA) in patients with osteoarthritis remain debated. This updated systematic review and meta-analysis aimed to further evaluate the role of tourniquets use in patients undergoing TKA for knee osteoarthritis by introducing trial sequential analysis.

METHODS

PubMed, Embase, and the Cochrane Library were searched. We used the Cochrane risk of bias tool for quality assessment. Statistical heterogeneity across studies was evaluated using Cochran's Q and I2 statistic. Meta-analysis was performed using Stata/SE 14.0, and trail sequential analysis was performed using TSA software version 0.9.5.10 Beta. In addition, qualitative summary was also used to describe results.

RESULTS

15 randomized controlled trials (RCTs) involving 1202 patients were included in the meta-analysis. The pooled results showed that tourniquet use during TKA significantly reduced intraoperative blood loss (mean difference (MD)= -123.84, 95% confidence interval (CI): -163.37 to -84.32, p < .001)and shortened operation time (MD = -4.71, 95% CI: -7.6 to -1.82, p = .001), but there were no significant differences in postoperative blood loss, calculated blood loss, total blood loss, transfusion rate (p = .939), and deep venous thrombosis (DVT) rate between the tourniquet and no-tourniquet groups. TSA confirmed that the result of operation time was false positive, but the results of other outcomes were conclusive. The results of qualitative summary showed conflicting findings in terms of pain, range of motion (RoM) and swelling ratio between the two groups.

CONCLUSIONS

Tourniquet use in patients receiving TKA for osteoarthritis benefits to reduce intraoperative blood loss but has no effect on postoperative blood loss, calculated blood loss, total blood loss, operation time, transfusion rate, and DVT rate. In addition, it remains unclear the difference between the tourniquet and non-tourniquet groups in terms of pain, RoM and swelling ratio.

The Impact of Tourniquet Usage on TKA Outcome: A Single-Center Prospective Trial

Background and Objectives: Total knee arthroplasties (TKAs) are the most effective surgical treatment for end-stage knee osteoarthritis. The tourniquet is used to reduce intraoperative blood loss, improving surgical field visualization. There is much controversy regarding the effectiveness and safety of using a tourniquet during total knee arthroplasties. The purpose of this prospective study is to determine the effect of tourniquet usage during TKAs on early functional outcomes and pain in our center. Materials and Methods: We conducted a randomized controlled trial of patients following a primary total knee replacement between October 2020 and August 2021. We recorded presurgical data, which included age, sex and knee range of motion. Intraoperatively, we measured the amount of blood aspiration and the surgical room time. After the surgery, we measured the amount of blood aspirated through the drains and the hemoglobin. We measured flexion, extension, Visual Analogue Scale (VAS) scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC score) scores for the functional evaluation. Results: We included 96 patients in the T group and 94 in the NT group, respectively, who remained until the last follow-up. Regarding blood loss, the NT group demonstrated significantly lower levels: 245 ± 97.8 mL intraoperative and 324.8 ± 151.65 mL postoperative, compared to the T group, where we recorded 276 ± 109.2 mL during the surgical procedures and 353.44 ± 101.55 mL after the surgery, (p < 0.05). We also recorded significantly shorter operative room time for the NT group, (p < 0.05). During the follow-up, we noticed postoperative improvements but without significant differences between the groups. Conclusions: We found a significant decrease in bleeding after no tourniquet usage during total knee replacements and shorter operative times. On the other hand, the knee function demonstrated no significant differences between the groups. Further studies may be required in order to assess complications.

Tourniquets can further reduce perioperative blood loss in patients on dexamethasone and tranexamic acid during cemented total knee arthritis: a single-center, double-blind, randomized controlled trial

BACKGROUND

Multiple doses of dexamethasone and tranexamic acid can inhibit postoperative inflammation and reduce fibrinolysis and perioperative blood loss in total knee arthroplasty. In this single-center, double-blind, randomized clinical trial, the aim was to investigate whether applying a tourniquet to patients on dexamethasone and tranexamic acid could further reduce perioperative blood loss.

MATERIALS AND METHODS

Patients who underwent cemented total knee arthroplasty at our hospital were randomized to receive a tourniquet (n = 71) or not (n = 70) during the procedure. All patients received multiple doses of dexamethasone and tranexamic acid perioperatively. The primary outcome was perioperative blood loss, while secondary outcomes were surgery duration, postoperative laboratory indices of inflammation and fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, and complications.

RESULTS

Using a tourniquet was associated with significantly lower intraoperative blood loss (P < 0.001) and total blood loss (P = 0.007) as well as significantly shorter surgery duration (P < 0.001). In contrast, the tourniquet did not significantly affect hidden blood loss, postoperative inflammation or fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, or complications.

CONCLUSIONS

The results of this randomized clinical trial demonstrate that applying a tourniquet during cemented total knee arthroplasty to patients receiving multiple doses of dexamethasone and tranexamic acid can further reduce perioperative blood loss without increasing the risk of inflammation, fibrinolysis, or other complications. Thus, it is advised to use tourniquets combined with dexamethasone and tranexamic acid to reduce perioperative blood loss and avoid tourniquet-related adverse events.

LEVEL OF EVIDENCE

Therapeutic Level I. Trial registration Chinese Clinical Trail Registry, ChiCTR2200060567. Registered 5 June 2022-retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=171291.

The Effect of Tourniquet Duration on Pain, Bleeding, and Functional Outcomes in Total Knee Arthroplasty

Objective The aim of this study was to evaluate the effects of tourniquet use on perioperative blood loss, pain, and functional and clinical outcomes. Patients and methods This is a prospective study that included 80 knees who underwent total knee arthroplasty. The patients were separated into two groups: those with a tourniquet used throughout the entire surgical procedure and those where the tourniquet was only used during the cementation procedure. In the postoperative period, the pain levels of the patients were evaluated using a visual analog scale (VAS), and the functional results were evaluated with knee range of motion measurement, the Western Ontario and Mcmaster Universities Osteoarthritis (WOMAC) index, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Kujala Patellofemoral Scoring System, and the Oxford Knee Scoring system. The patients were examined in the early postoperative period and again in the 12th week, including possible complications that may develop postoperatively. Results In the early postoperative period, a greater hemoglobin decrease and calculated blood loss values, better functional clinical results, and better knee range of motion were determined in the group with a tourniquet applied only during the cementation, and the swelling in the knee was less (p<0.05). However, the difference between the two groups had disappeared by the postoperative 12th week. There was no significant difference in respect of complications. Conclusion Limiting the duration of tourniquet use during total knee arthroplasty has the significant advantage of providing better functional results with less pain in the early postoperative period.

Tourniquet application in primary total knee arthroplasty for osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

Objective

The aim of this study was to identify the influence of a tourniquet on the blood loss, transfusion requirement, swelling, pain, knee function, range of motion (ROM), operation time, bone cement mantle thickness, and complications in patients operated with total knee arthroplasty (TKA).

Methods

Two authors independently retrieved PubMed, Embase, and CENTRAL to identify eligible randomized controlled trials (RCTs) evaluating the effectiveness of a tourniquet in TKA. Fixed- (I ²< 50%) or random-effects (I ²> 50%) models were selected to perform meta-analysis according to the value of I ². Mean difference (MD) and risk ratio were selected as the effect sizes for continuous and dichotomous variables, respectively.

Results

A total of 29 RCTs, involving 2,512 operations (1,258 procedures with a tourniquet and 1,254 procedures without a tourniquet), were included, and 18 outcomes were compared. Tourniquet application could significantly decrease intraoperative blood loss (MD = -138.72 ml, p < 0.001), shorten operation duration (MD = -1.77 min, p < 0.001), and increase cement mantle thickness (MD = 0.17 mm, p < 0.001). However, it was significantly associated with increased postoperative pain intensity, decreased full ROM/flexion ROM/extension ROM, poorer knee function, increased knee swelling, and increased length of hospital stay (LOS) at several follow-up points (p < 0.050). No significant difference was found for postoperative draining volume, total blood loss, transfusion rate, change of Hb level, and risks of deep venous thrombosis and all complications.

Conclusions

Tourniquet application could only decrease the intraoperative blood loss but has no effectiveness on the total blood loss and transfusion requirement. On the contrary, it has a reverse effect on the pain score, knee function, ROM, swelling, and LOS.

Effects of the Use of Tourniquet in Total Knee Arthroplasty on the Clinical and Functional Outcomes with 5 Years of Follow-up: A Randomized Controlled Trial

The use of tourniquet in total knee arthroplasty (TKA) had a lot of controversies with no clear agreement about the advantages and disadvantages of tourniquet. This study aims to show the effects of tourniquet use in TKA on the functional and clinical outcomes with follow-up of 5 years. This is a randomized, double-blind, and single-center study of 101 patients who were treated by TKA and divided randomly into two groups. Tourniquet was used in group A and was not used in group B. Both groups were assessed by Knee Society score (KSS), knee injury and osteoarthritis outcome score (KOOS), visual analogue scale (VAS) score for thigh pain, and postoperative complications. Both groups were followed up for 5 years. The group of no tourniquet showed significant better functional outcomes measured by KSS at postoperative periods of 2 weeks (p = 0.001), 6 weeks (p = 0.006), and 3 months (p = 0.034), and KOOS at postoperative periods of 2 weeks (p = 0.001), 6 weeks (p =0.001), and 3 months (p = 0.016). However, there was no significant difference in long-term follow-up of 5 years. There were significantly better results with use of tourniquet regarding surgeon's visualization during surgery, less operative time, and less calculated blood loss, while significantly better results with no use of tourniquet were reported regarding less hospital stay, less postoperative analgesic consumption, and less postoperative thigh pain measured by VAS score at postoperative periods of day 1 (p = 0.001), day 5 (p = 0.001), 2 weeks (p = 0.001), and 6 weeks (p = 0.001). Regarding postoperative blood transfusion and clinical deep venous thrombosis, there was no significant difference between use of tourniquet or not. The evidence presented in this level-1 randomized controlled trial suggests that no use of tourniquet in TKA can improve functional outcomes in early postoperative period with no significant difference on functional outcome at 5 years of follow-up.

Optimization of surgical tourniquet usage to improve patient outcomes: Translational cross-disciplinary implications of a surgical practice survey

Tourniquet use is common practice in many millions of orthopaedic procedures annually. Recent reviews of risks and benefits of surgical tourniquet use have primarily involved meta-analyses, many of which have forgone a comprehensive risk-benefit analysis to simply question whether "tourniquet or no tourniquet" use produces improved patient outcomes, often leading to limited, inconclusive, or conflicting results. To investigate further, a pilot survey was undertaken to determine current practices, opinions, and understandings among orthopaedic surgeons in Canada regarding use of surgical tourniquets in total knee arthroplasties (TKAs). Results of the pilot survey showed a wide range of understanding and practice associated with tourniquet use in TKAs, especially regarding tourniquet pressures and tourniquet times, two key factors known from basic research and clinical studies to impact the safety and efficacy of tourniquet use. The wide variation of use indicated by the survey results reveals important implications for surgeons, researchers, educators, and biomedical engineers, to better understand the association between key tourniquet parameters and outcomes assessed in research, which may be factors leading to their often limited, inconclusive, and conflicting results. Lastly, we provide an overview of the overly simplified assessments of tourniquet use in meta-analyses, whose conclusions may not provide an understanding of how or whether key tourniquet parameters might be optimized to retain the benefits of tourniquet use while mitigating the associated real or perceived risks.

Bilateral Total Knee Arthroplasty: Current Concepts Review

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Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days.

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Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others.

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While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA.

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When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart.

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Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.

Tourniquet use during primary total knee arthroplasty-a survey of Irish orthopaedic surgeons in 2022

BACKGROUND

Tourniquet use during primary total knee arthroplasty is a debated topic in the literature with no consensus on its optimal use.

AIM

To analyse current tourniquet practice amongst Irish orthopaedic surgeons performing primary total knee arthroplasty surgery. To evaluate if there has been a shift in practice in recent years and to explore potential reasons behind this.

METHODS

An eleven-question online survey was developed using the online platform SurveyMonkey. This was distributed by email to Irish orthopaedic surgeons via the Irish Institute of Trauma and Orthopaedic Surgery.

RESULTS

Fifty responses were included in the final analysis of this study. Eighteen (36%) respondents reported changing their tourniquet use in the past 5 years. Thirty-one (62%) respondents reported inflating the tourniquet for the entire case, with the remaining never applying a tourniquet (n = 6, 12%), applying a tourniquet but not routinely inflating it (n = 3, 6%), or inflating the tourniquet only during cementation (n = 5, 10%). The number of years of experience as a consultant appeared to impact tourniquet use in a bimodal pattern.

CONCLUSION

While the majority of Irish orthopaedic surgeons in this survey inflate a tourniquet for the entire surgical procedure, there is a definite shift towards reduced tourniquet use compared to previous Irish, UK, and American surveys.

Defining tourniquetless total knee arthroplasty: A systematic review

Introduction

Performing total knee arthroplasty (TKA) without the use of tourniquet is gaining popularity. However, performing a "tourniquetless TKA" has a variety of meanings regarding the timing and application of a tourniquet and associated techniques. The purpose of this systematic review was to evaluate the literature and more accurately define "tourniquetless TKA."

Methods

A systematic review following PRISMA guidelines was performed of the PubMed, Web of Science, and Cochrane databases for articles published from 2016 to 2021. Inclusion criteria included papers that used "tourniquetless" or a similar term to describe their TKA procedure, original clinical studies, English language, and full-text studies.

Results

A total of 1,096 studies were identified, of which 84 full text studies with 9,349 total patients were included. Overall, 17 (20.2%) of the studies performing tourniquetless TKA never applied a tourniquet, 17 (20.2%) applied a tourniquet but kept it deflated throughout the entire procedure, 2 (2.4%) applied a tourniquet and inflated during cementation only, and 48 (57.1%) did not specify. Ultimately, of the studies that did specify tourniquet use, only 17 studies (47.2%) truly never applied a tourniquet throughout the procedure. A review of 7 recommended techniques to control blood loss in tourniquetless TKA found that no one technique was performed in more than 10.6% of patients.

Conclusion

Variation in the definition of tourniquetless TKA and the utilization of augmented techniques to control blood loss remains. We propose the terms "tourniquetless" for no tourniquet application, "tourniquet-available" for tourniquet applied but kept deflated throughout surgery, and "tourniquet-assisted" for tourniquet inflation during cementation only. These terms can help better differentiate the literature, guide surgeons as they transition to tourniquetless TKA, and assist in the development of more definitive protocols for tourniquetless TKA.

Blood Transfusion can be Avoided in Single-Anesthetic Bilateral Total Knee Arthroplasty

BACKGROUND

Female gender and surgical drain use have been associated with an increased transfusion risk following single-anesthetic bilateral total knee arthroplasty (SBTKA). This study evaluated allogenic blood transfusion rates among female and male patients undergoing SBTKA with intraoperative tourniquet, tranexamic acid and contemporary blood transfusion thresholds but without surgical drain use.

METHODS

We performed a retrospective electronic medical record review for 125 consecutive patients undergoing SBTKA (250 knees) between May 1, 2015 and July 10, 2021. Patient demographic characteristics (age, gender, body mass index, American Society of Anesthesiologists), preoperative and postoperative hemoglobin levels, perioperative transfusions, operative time, and hospital length of stay were compared between 76 female (60.8%) and 49 male (39.2%) patient cohorts using paired Student's t-test or Fisher's exact test with a P value <.05 for significance.

RESULTS

No patient in either gender-based cohort received a perioperative allogeneic or autologous blood transfusion (P = 1). There were no significant differences in patient demographic features or medical comorbidities. Male patients had significantly higher mean preoperative (14.7 versus 13.7 g/dL, P < .01) and postoperative (12.7 versus 11.8 g/dL, P < .01) hemoglobin levels and a shorter mean hospital length of stay (2.5 versus 3.0 days, P < .01). There was no difference in the mean operative time (154.7 versus 150.7 minutes, P = .34) or change in the hemoglobin level (2.1 versus 1.9 g/dL, P = .27).

CONCLUSION

SBTKA can be performed with a limited risk of perioperative transfusion with a combination of intraoperative tourniquet, tranexamic acid, conservative blood transfusion criteria, and avoidance of postoperative drain use. Study results were not influenced by patient gender.

LEVEL OF EVIDENCE

This is a level III, retrospective cohort study.

Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures - A Systematic Review and Meta-Analysis

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.

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.

Assessment of Short-Term Outcomes of Total Knee Arthroplasty Performed With and Without a Tourniquet

Background: Tourniquet use has been advocated for better visualization of the surgical field as it exsanguinates most of the blood from the limbs to the central compartment. On the contrary, its use may increase postoperative pain and recovery of quadriceps function, thereby increasing the length of stay (LOS). The study aims to assess short-term outcomes of total knee arthroplasty (TKA) performed with and without a tourniquet.

Methodology: Eighty-six patients scheduled for TKA either with or without a tourniquet were selected and divided into two groups using simple random sampling. Knee replacements were performed with a tourniquet in group I and without a tourniquet in group II. In all cases, blood loss was estimated. A visual analog scale (VAS) was used for the assessment of postoperative pain. In the study, range of motion (ROM) and quadriceps lag were also assessed on postoperative day 2 and discharge.

Results: There were 23 (26.7%) males and 20 (23.2%) females in group I and 28 (32.5%) males and 15 (17.4%) females in group II (p = 0.07). On comparing mean age and body mass index (BMI), statistically insignificant results were obtained. In group I and group II, a statistically significant difference was obtained in the estimation of mean total blood loss as 780.4 ± 152.49 and 1146.2 ± 193.14 ml, respectively (p = 0.02). Neither on postoperative day 2 nor at the time of discharge, no significant results were obtained in observing the ROM at the knee joint and quadriceps lag.

Conclusion: It was found that tourniquet use is associated with lower blood loss and similar postoperative pain, ROM, quadriceps lag, and LOS.

The mid-term and long-term effects of tourniquet use in total knee arthroplasty: systematic review

PURPOSE

A tourniquet is routinely used during total knee arthroplasty (TKA) to reduce intra-operative hemorrhage, though surgery without a tourniquet is becoming popular. To address concerns about the effect of blood at cement interfaces on long-term implant stability, we conducted a systematic review among patients undergoing total knee arthroplasty to determine if TKA with a tourniquet, compared to TKA without a tourniquet or with reduced tourniquet duration, is associated with better mid-term and long-term implant stability.

METHODS

A literature search was conducted without language restriction in PubMed, Cochrane database and Web of Science from conception to 17th March, 2021. Prospective cohorts, randomized and observational, that compared tourniquet use with a control group, followed patients for 3 months or more and reported outcomes concerning implant stability, limb function, pain and inflammation. Article selection, quality assessment according to the Revised Cochrane risk assessment scale and Newcastle Ottawa Scale, and data extraction were conducted in duplicate.

PROSPERO

CRD42020179020.

RESULTS

The search yielded 4868 articles, from which 16 randomized controlled trials (RCT) and four prospective cohort studies, evaluating outcomes of 1884 knees, were included. Eleven RCTs were evaluated to be low overall risk of bias, five RCTs had some concerns and four cohort studies were good quality. Few studies showed benefits of tourniquet use in mid-term implant stability (1/6), pain (1/11) and limb inflammation (1/5), and long-term implant stability (1/1). One study reported a significantly improved range of motion (1/14) while another reported significantly reduced quadriceps strength (1/6) in the tourniquet group. The remaining studies reported non-significant effect of tourniquet use.

CONCLUSION

Although few studies indicated benefits of tourniquet use in mid-term pain, limb inflammation, implant loosening and function, and long-term implant loosening, the majority of studies report no significant advantage of tourniquet use in total knee arthroplasty.

A Randomized Controlled Study on the Use of Tourniquet in Primary Total Knee Arthroplasty

BACKGROUND

 The use and the optimal timing of tourniquet during primary total knee arthroplasty (TKA) is controversial. Most previous studies failed to show clinically significant differences in different strategies. The aim of this study was to determine how three strategies of tourniquet application affect the outcome in TKA patients.

METHODS

 This was a prospective randomized controlled study. Patients who undergo TKA were randomized into one of the three groups (1:1:1 ratio): tourniquet inflated from skin incision to cement hardening, tourniquet from cement application to hardening, and tourniquet from skin incision to skin closure. The perioperative blood loss, limb swelling, and complications were recorded. The level of hemoglobin, hematocrit, C-reactive protein (CRP), interleukin (IL)-6, creatine kinase (CK), and lactate dehydrogenase (LDH) were determined. Patients' thigh and TKA wound pain, Knee Society knee score (KSKS) and Knee Society functional assessment (KSFA) scores, and rehabilitation parameters were evaluated.

RESULTS

 A total of 90 patients were enrolled. The baseline characteristics were comparable. We only found significant difference in the intraoperative blood loss (skin to cement: 58.7 ± 36.1 mL, cement-only: 147.8 ± 107.9 mL, skin to skin: 16.3 ± 13.1 mL, p < 0.0001). There were no statistical differences in postoperative drainage, thigh/knee circumference, change of hemoglobin/hematocrit, CRP, IL-6, CK, and LDH on day 1 to day 4 after surgery. The thigh/TKA wound Visual Analogue Scale scores, KSKS score, KSFA score, and rehabilitation parameters were not significantly different at up to 6-month follow-up. No thromboembolic events were noted.

CONCLUSION

 Our results revealed that there was no best tourniquet strategy in TKA. Different tourniquet methods can be utilized based on surgeon preference without affecting outcomes.

Lower tourniquet pressure does not affect pain nor knee-extension strength in patients after total knee arthroplasty: a randomized controlled trial

PURPOSE

The use of a tourniquet in total knee replacement has advantages and drawbacks. Some studies suggest that using ischaemia at low pressures could reduce its negative effects. Our objective is to verify whether the use of ischaemia at low pressures (100 mmHg above the systolic blood pressure) produces greater pain and loss of strength than surgery without a tourniquet.

METHODS

By the means of a prospective randomized clinical trial, patients were assigned to the control group (no tourniquet, NT) or the experimental group (tourniquet, T). The main variables measured were pain (VAS) and isometric muscle strength (preoperatively, 10 days and 3 months after surgery). Secondary variables were haemoglobin at 24 h, transfusion index, need for rescue drugs and days of admission.

RESULTS

A total of 71 patients (73 prosthesis) were studied. Both groups were homogeneous in terms of age, body mass index, sex ratio, preoperative strength and level of anesthetic risk. We did not find significative differences in any of the main variables (pain and strength) nor in the secondary ones. We could only find differences in the days of admission (2.77 vs. 3.05; p = 0.031).

CONCLUSIONS

Use of a tourniquet at low pressures (100 mmHg above systolic blood pressure) did not result in an increase in postoperative pain or a decrease in quadriceps extension force within the first 3 months after surgery.

LEVEL OF EVIDENCE

Level 1-Randomized controlled trial.

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.

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.

Change in the optic nerve sheath diameter after deflation of a pneumatic tourniquet: a prospective observational study

Applying a pneumatic tourniquet provides surgeons with a bloodless surgical field. However, application of the tourniquet induces various physiological changes. We evaluated the effect of tourniquet deflation on the intracranial pressure by using ultrasonography to measure the optic nerve sheath diameter (ONSD) in patients undergoing lower limb surgery. The ONSD was measured in 20 patients at five time points: after anesthetic induction (T0) and immediately before (T1), immediately after (T2), 5 min after (T3), and 10 min after tourniquet deflation (T4). Hemodynamic and respiratory variables were recorded. The ONSD showed significant differences at each point (P < 0.001). The ONSDs at T2 and T3 were significantly greater than that at T1 (P = 0.0007 and < 0.0001, respectively). The change in the end-tidal carbon dioxide partial pressure (EtCO2) was similar to the change in the ONSD. The change in the ONSD was significantly correlated with the change in the EtCO2 after tourniquet deflation (r = 0.484, P = 0.030). In conclusion, the ONSD, as an indicator of intracranial pressure, increased after tourniquet deflation in patients undergoing lower limb surgery. This was correlated with an increased EtCO2 and arterial carbon dioxide partial pressure.Trial registration: ClinicalTrials.gov (NCT03782077).

Outcomes of Tourniquet-Less Revision Total Knee Arthroplasty: A Matched Cohort Analysis

INTRODUCTION

A tourniquet is routinely used in total knee arthroplasty (TKA) to limit perioperative blood loss and increase the visibility of the surgeon's field of view. This study aims to evaluate the postoperative clinical outcomes and complications associated with tourniquet use in revision TKA.

METHODS

We conducted a retrospective review of 1,904 consecutive patients who underwent revision TKA. Propensity score-based matching was done to adjust for baseline differences in patient demographics and procedure details.

RESULTS

Propensity score matching resulted in a cohort of 548 revision total joint arthroplasty patients, 274 (50.0%) of whom were tourniquet patients matched to 274 (50.0%) tourniquet-less patients. Multivariate regression analyses demonstrated that, compared with the tourniquet-less cohort, the tourniquet cohort had significantly less intraoperative (413.7 to 353.2 mL, P < 0.01) and total perioperative (1,548.7 to 1,417.8 mL, P < 0.01) blood loss. However, no significant differences were present in total perioperative (8.4%, 6.6%, P = 0.43) transfusion rates. The tourniquet cohort had increased length of stay (3.2 to 3.7 days, P < 0.001) and 30-day readmissions (P = 0.04).

DISCUSSION

This study demonstrated that although omitting the tourniquet in revision TKA leads to markedly increased perioperative blood loss, notable differences in perioperative transfusion rates were not observed. Furthermore, revision TKA without tourniquet use was associated with reduced postoperative length of stay, 30-day readmissions, and increased range of flexion.

Tourniquet Use Does Not Affect Pain and Function after Total Knee Arthroplasty: Patient Evaluation According to Pain Threshold

We evaluated the effect of using a tourniquet on early-stage pain and 1-year postoperative functional outcomes when patients were divided into two groups according to the pain threshold (PT). Overall, 120 patients who were assessed preoperatively with an algometer were recruited for this prospective, double-blinded, randomized controlled trial. Patients were randomized to undergo total knee arthroplasty (TKA) with a tourniquet (group 1, 60 patients) and without tourniquet (group 2, 60 patients). Primary outcome measures were visual analog scale (VAS) pain scores at 24, 36, and 48 hours postoperatively and functional assessment with Knee Society Score (KSS) test at 1 year postoperatively. No significant differences were observed between groups in terms of gender (49 females and 8 males in group 1 vs. 53 females and 6 males in group 2; p = 0.201) and age (68.9 years in group 1 vs. 68.7 years in group 2; p = 0.811). There was no significant difference between groups in all the VAS and KSS 1 and KSS 2 scores. PT measurements ranged from 2.5 to 11.5 with a mean of 7.69 ± 1.70 and a median of 8. Total 54 patients with a median value of < 8 were defined as the low-PT group, and 62 patients with a median value of ≥ 8 were defined as the high-PT group. When the groups were evaluated according to using the tourniquet, 21 patients were operated on with a tourniquet and 33 patients without it in the low-PT group, while 36 patients were operated on with a tourniquet and 26 patients without it in the high-PT group. There was no significant difference in pain or functional scores between patients when comparing with-tourniquet and without-tourniquet or when comparing the low- and high-PT groups. This showed that the use of a tourniquet during TKA was not associated with either early-stage pain or 1-year postoperative functional outcomes according to algometer evaluation.Level of evidence: Level 1 prospective randomized 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.

Impact of tourniquet on short-term outcomes in opening wedge high tibial osteotomy with modern tranexamic acid protocols: a retrospective cohort study

BACKGROUND

The use of a tourniquet during high tibial osteotomy (HTO) is a routine procedure, but there is currently no research on the benefits and potential risks of tourniquet use during HTO. The aim of this study was to investigate the impact of tourniquet on perioperative blood loss, early functional recovery and complications in opening wedge HTO with modern tranexamic acid protocols.

METHODS

This was a retrospective cohort study of patients who underwent unilateral opening wedge HTO between January 2019 and September 2020. All patients were divided into two groups according to whether a tourniquet was applied during HTO. Patients in both groups received the same surgical procedures, tranexamic acid protocols and other perioperative treatments. Preoperative baseline data, intraoperative data, early postoperative recovery and all complications during the 3-month follow-up were collected and compared between the two groups.

RESULTS

A total of 62 patients were enrolled in this study, including 32 in the tourniquet group and 30 in the non-tourniquet group. There was no significant difference in preoperative baseline data between the two groups (P > 0.05 in all). Intraoperative blood loss in the tourniquet group was significantly lower than that in the non-tourniquet group (80.22 ml versus 94.00 ml, P < 0.001), but there was no difference in total blood loss (187.39 ml versus 193.31 ml, P = 0.714). And no patient in either group required blood transfusion. In terms of early postoperative recovery, tourniquet use significantly increased pain scores and reduced knee range of motion on the first and second postoperative days, but there was no significant difference between the two groups at postoperative third day and third month. Furthermore, there was no significant difference between the two groups in terms of lower limb force line correction, length of stay, Knee Society Score or the incidence of complications during the 3-month follow-up (P > 0.05 in all).

CONCLUSIONS

In opening wedge HTO with modern tranexamic acid protocols, not using a tourniquet does not increase perioperative total blood loss or the risk of complications, but facilitates early postoperative recovery by reducing pain and increasing range of motion.

Use of a Tourniquet and Spinal Anesthesia Increases Satisfactory Outcomes After Total Knee Arthroplasty: A Randomized Study

BACKGROUND

Total knee arthroplasty (TKA) is usually performed successfully with or without a tourniquet and under spinal anesthesia (SA) or general anesthesia (GA). However, 10% to 34% of patients experience dissatisfaction and pain after TKA. We aimed to compare the effects of tourniquet use and SA or GA on TKA outcomes.

METHODS

We randomly assigned 404 patients to 4 study groups: SA without a tourniquet (NT/SA), SA with a tourniquet (T/SA), GA without a tourniquet (NT/GA), and GA with a tourniquet (T/GA). The primary outcome was the change in the Oxford Knee Score (OKS) at 1 year postoperatively. Secondary outcomes included a satisfactory TKA outcome assessed using the OKS minimal important change (MIC) and OKS patient acceptable symptom state (PASS), adverse events, and quality of life using the 15-dimensional health-related quality of life tool.

RESULTS

At 1 year, the OKS was obtained for 381 patients. In the 2-group comparisons, the tourniquet did not affect the OKS improvement. The SA group had more substantial improvement in the OKS than the GA group (16.21 compared with 14.08 a mean difference of 2.13; 95% confidence interval [CI], 0.55 to 3.71; p = 0.008). In the 4-group comparisons, the T/SA group had more substantial improvements in the OKS than the NT/GA group (16.87 compared with 13.65, a mean difference of 3.2; 95% CI, 0.28 to 6.17; p = 0.026). The SA group reached the OKS MIC more frequently than the GA group (91.7% compared with 81.7%; odds ratio [OR] = 2.49 [95% CI, 1.32 to 4.69]; p = 0.005). The SA group also reached the OKS PASS more frequently than the GA group (86.0% compared with 75.7%; OR = 2.00 [95% CI, 1.18 to 3.39]; p = 0.010). The T/SA group had significantly more patients reaching the OKS MIC than the NT/GA group (95.7% compared with 79.6%; p = 0.005) and more patients reaching the OKS PASS than the NT/GA group (92.6% compared with 74.5%; p = 0.004). No differences were seen with respect to adverse events in any comparisons.

CONCLUSIONS

The tourniquet had no detrimental effects on the outcomes of TKA. SA had a positive effect on the OKS. The use of SA combined with a tourniquet resulted in the best improvement in OKS and the highest proportion of satisfactory outcomes with TKA.

LEVEL OF EVIDENCE

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

Enhanced recovery after surgery protocols in total knee arthroplasty via midvastus approach: a randomized controlled trial

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols were rapidly adopted in many surgeries such as fast-track arthroplasty. The study aimed to investigate the impact of ERAS protocols on the clinical effect of total knee arthroplasty (TKA) via the midvastus approach.

METHODS

A total of 69 patients who underwent primary unilateral TKA via the midvastus approach from October 2018 to June 2019 were enrolled and randomly divided into two groups: ERAS group and Control group. The ERAS protocols were adopted for the ERAS group and consisted of pure juice drinking 2 h before the surgery, optimization of the preoperative anesthesia plan, phased use of tourniquets, and the use of tranexamic acid as well as a drug cocktail. The operative time, first postoperative walking time, first straight leg elevation time, postoperative hospitalization time, visual analogue scale score (VAS score), Hospital for Special Surgery score (HSS score), conventional Knee Society score (KSS), and knee range of motion (ROM) were used to assess the clinical effects in the two groups. All the included patients were followed up for 12 months.

RESULTS

There were no significant differences in the basic demographic information and operation time between the ERAS and Control groups (P > 0.05). The first postoperative walking time (2.11 ± 0.11 h) and first postoperative straight leg elevation time (6.14 ± 1.73 h) in the ERAS group were significantly earlier than those in the Control group (P < 0.001) and the postoperative hospitalization time was significantly shorter (3.11 ± 0.32 days). The postoperative mean VAS scores in both groups were significantly reduced compared with those before surgery (P < 0.001). The VAS scores for the ERAS group were significantly lower than those for the Control group at 1, 2, and 7 days after surgery (P < 0.001). The mean HSS scores, KSS, and knee ROM were significantly increased in both the ERAS and Control groups at 1, 3, 6, and 12 months after surgery (P < 0.001). In addition, the HSS scores, KSS, and knee ROM in the ERAS group were significantly higher than those in the Control group at 1 month after surgery (P < 0.001).

CONCLUSIONS

ERAS protocols improved the clinical effects of TKA via the midvastus approach, facilitating early out-of-bed activity and comfortable postoperative rehabilitation exercise, and further increasing patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04873544 .

Safety and Blood Loss Associated With Tourniquets in Total Knee Arthroplasty

Objective

To measure total blood loss and safety of tourniquets, tourniquets during cementation, or no tourniquets during total knee arthroplasty (TKA).

Methods

This retrospective cohort study included 75 patients from King Khalid University Hospital in Riyadh, Saudi Arabia. Patients were equally divided into three groups: tourniquets, no-tourniquets, and tourniquets during cementation. Recorded data included: baseline characteristics (age, sex, weight, height, body mass index (BMI), anesthesia type, and comorbidities), blood loss parameters (total blood loss, preoperative and postoperative hematocrit (Hct) and hemoglobin (Hgb), and blood transfusion units), duration of surgery, hospital stay, and thromboembolic events during 3-months postoperatively. Statistical significance was reported by using a P-value < 0.05, and 95% confidence intervals.

Results

The tourniquet group had significantly lower mean total blood loss (544.67 mL ± 418.86; P = 0.001), higher mean postoperative hemoglobin values (115.44 g/dL ± 10.97; P = 0.004) and hematocrit (34.25 % ± 3.35; P = 0.005), and lower median intra-operative loss (100 cc, 10-300; P < 0.001), than the other groups. Tourniquets during cementation required significantly more mean surgery time (131.84 minutes ± 22.12; P = 0.003), and longer median hospital stay (8 days, 5-13) than the other groups.

Conclusion

Tourniquet use during TKA significantly decreased total and intraoperative blood loss, but it did not have any significant effect on the transfusion rate or the incidence of thromboembolic events.

Perioperative Blood Loss Can Be Reduced If Total Knee Arthroplasty Was Performed in the Si Hour-Period, Compared with the Wei Hour-Period: A Retrospective Cohort Study

OBJECTIVE

To investigate the efficacy and safety of performing primary unilateral total knee arthroplasty (TKA) in the "Si hour-period" meaning 09:00 a.m. to 11:00 a.m. (one of the 12 two-hour periods into which the day was traditionally divided, each being given the name of one of the 12 earthly branches), compared with the "Wei hour-period" (13:00-15:00).

METHODS

Patient documentations were studied for those who underwent a primary unilateral TKA performed by the same surgical team with a tourniquet between January 2018 and January 2021 at our medical center. Eighty-four patients were enrolled and assigned into group A (in Si hour-period) and group B (in Wei hour-period). The main outcomes were total blood cell loss (TBL), hidden blood loss (HBL), visible blood loss (VBL), maximum hemoglobin (Hb) drop, and transfusion rate. Secondary outcomes were length of hospital stay (LOS), postoperative femorotibial mechanical axis (FTMA), FTMA correction, platelet count, plasma D-dimer (D-D), prothrombin time (PT), international normalized ratio (INR), and the incidence of postoperative complications.

RESULTS

Group A showed statistical significance lower at the mean TBL, the mean HBL, and the maximum Hb drop (95% CI: -352.8 to -46.1,P=0.011, 95% CI: -348.0 to -40.1,P=0.014, and 95% CI: -9.5 to -0.7,P=0.023, respectively) after TKA than group B. The postoperative platelet count of group A was more significant than that of group B (95% CI:3.1 to 52.9, P=0.028). The VBL, transfusion rate, the LOS, postoperative FTMA, FTMA correction, plasma D-D, PT, INR, and the incidence of postoperative complications (wound complications, calf muscular vein thrombosis, infection, pulmonary embolism, and deep vein thrombosis) were similar between the two groups (P > 0.05, respectively).

CONCLUSION

Our study shows that blood loss can be reduced when TKA is performed in the "Si hour-period," which may be due to increasing platelet count, and postoperative complications did not increase, compared with the Wei hour-period. We recommend that the selective operation, such as TKA, should be performed in the "Si hour-period" in clinical practice between the two hour-period.

Tourniquet Use Improves Cement Penetration and Reduces Radiolucent Line Progression at 5 Years After Total Knee Arthroplasty

BACKGROUND

Although the effect of tourniquet use during total knee arthroplasty (TKA) on functional outcomes is controversial, there are little data examining cement penetration and implant stability. This study examines the effect of tourniquet use on cement penetration and radiolucent line (RLL) progression.

METHODS

Patients undergoing primary total knee arthroplasty with a single surgeon, implant, and cement with minimum 5-year follow-up were retrospectively reviewed. Tourniquet use was defined as 30 minutes minimum, while no tourniquet was 0 minutes. Patients were 1:1 matched (n = 61 per group) by age (±5), gender, body mass index (±5), and follow-up (±2 years). Cement penetration and RLL were measured on the tibia at 6 weeks, and RLL at 1, 2, and 5 years postoperatively using the Knee Society Radiographic Evaluation System.

RESULTS

Cement penetration was significantly increased in the tourniquet group in anterior-posterior zones 1 (2.16 vs 1.03 mm, P < .0005), 2 (2.23 vs 1.51 mm, P < .0005), and 5 (8.56 vs 6.3 mm, P = .009), and lateral zones 1 (2.89 vs 2.17 mm, P < .0005), 2 (2.86 vs 2.12 mm, P < .0005), 3P (3.99 vs 3.5 mm, P = .039), and 5 (8.18 vs 5.93 mm, P = .006). Cumulative cement penetration averaged 34.48 vs 43.33 mm in the tourniquet group (P < .005). Progression of RLL >2 mm was observed in 27.8% (17/61) vs 11.4% (7/61) of patients in the tourniquet group (P < .005). There were 2 failures for aseptic tibial loosening in the no tourniquet group.

CONCLUSION

Tourniquet use improves cement penetration and reduces RLL progression. Dryer surfaces during cementation may improve penetration, resulting in superior initial fixation strength and potentially reducing the long-term risk of aseptic loosening.

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Tourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes.

METHODS

Patients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected.

RESULTS

Visual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent.

CONCLUSION

This study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.

Simultaneous Bilateral Total Knee Arthroplasty Becomes Safer after Institution of Optimal Perioperative Management: A Longitudinal Cohort Study

Simultaneous bilateral total knee arthroplasty (SBTKA) increases the rates of procedure-related complications and mortality compared with unilateral TKA. There are no well-defined guidelines for selecting patients to avoid mortality and proposing an upgrade treatment to decrease complication rates. This study aimed to evaluate whether optimal perioperative management could improve the safety of SBTKA. From 2005 to 2017, 1,166 cases of SBTKA were identified from 14,209 TKA procedures. We retrospectively examined the SBTKA patients' demographics, comorbidity profiles, procedure-related complications, and perioperative management during two time periods. Optimal perioperative workup for managing SBTKA significantly decreased the incidences of major complication from 6.2 to 2.4% (p = 0.001) and minor complications from 28.9 to 21.5% (p = 0.004) during period I and period II, respectively. The efficiency of less tourniquet use along with intraarticular tranexamic acid injection was demonstrated by the decreases of hemoglobin (Hb) change in the first 2 days after surgery (p = 0.005) and blood transfusion requirement (p = 0.035) during the SBTKA. Furthermore, the less tourniquet use group had less thigh pain (visual analog scale decreased from 6.0 to 4.2, p = 0.003), shorter duration of hospital stay (decreased from 7.8 to 7.1, p < 0.001), and lower coagulation time (decrease from 3.5 to 2.9, p < 0.001) than the routine tourniquet use group. Patient's screening must be performed carefully for cardiopulmonary compromise in patients aged >80 years and with an American Society of Anesthesiologists score of 3. Additionally, hospitalists should consider developing methods for the eligibility, testing, and perioperative monitoring of patients who undergo SBTKA with the aim of avoiding complications and improving outcomes.

Tourniquet use in primary total knee arthroplasty is associated with a hypercoagulable status: a prospective thromboelastography trial

STUDY DESIGN

Prospective study.

PURPOSE

The main purpose of this study was to investigate whether the use of a tourniquet changes the blood coagulation state following primary total knee arthroplasty (TKA) by means of conventional coagulation tests and thromboelastography (TEG) analyses.

METHODS

A total of 154 patients who underwent primary unilateral TKA from January 2018 to October 2020 were enrolled. Seventy-nine patients were randomized into a tourniquet group, and 75 were randomized into a no-tourniquet group. Demographic data, surgical time, intra-operative blood loss, transfusion rate, and wound complications were collected. Complete blood count, conventional coagulation tests, and TEG were performed the day before surgery, one day after surgery, three days after surgery, and seven days after surgery. Lower extremity Doppler ultrasound was performed the day before surgery and seven days after surgery.

RESULTS

The baseline characteristics of the patients were similar between the two groups. Hidden blood loss, transfusion rate, and wound complications were similar between the two groups, but the intra-operative blood loss of the tourniquet group was lower than that of the no-tourniquet group. The calculated total blood loss of the tourniquet group was higher than that of the no-tourniquet group. In terms of conventional coagulation tests and TEG, the tourniquet group had higher values of fibrin degradation products, D-dimer, maximum amplitude, and coagulation index (p < 0.001). The incidence of deep vein thrombosis (DVT) in the tourniquet group was higher than that in the no-tourniquet group (21.5% compared with 8%; p = 0.019).

CONCLUSION

The application of a tourniquet during TKA significantly increases the amount of calculated total blood loss and does not decrease the post-operative transfusion rate. Using a tourniquet in routine TKA exacerbates the early post-operative hypercoagulable status together with a higher incidence of below-knee asymptomatic DVT observed via conventional coagulation tests, TEG, and ultrasonic Doppler.

A comparison of thrombosis in total knee arthroplasty with and without a tourniquet: a meta-analysis of randomized controlled trials

Background

Tourniquets are widely used in total knee arthroplasty (TKA), but the issue of their safety remains controversial. Previous studies have focused on TKA blood loss, duration of surgery, and hemostatic drugs. The purpose of this meta-analysis was to analyze the effect of tourniquet use on postoperative deep venous thrombosis (DVT).

Methods

PubMed, SCOPUS, Web of Science, Embase, and the Cochrane Library were searched for randomized clinical trials published before April 17, 2020, that compared the effect of tourniquet use on postoperative DVT, knee circumference, D-dimers, and pain measured using the visual analog scale (VAS).

Results

Fourteen clinical trials that included 1321 unique participants were included in the meta-analysis. Among the total, 721 and 600 participants were randomized to the tourniquet and non-tourniquet groups, respectively. The incidence of postoperative thrombosis in the tourniquet group was significantly higher than in the non-tourniquet group (RR 2.30, 95% CI 1.51–3.49, P < 0.0001, I² = 0%). On the 1st, 3rd, and 5th to 21st days, and 3 to 6 weeks after surgery, the knee circumference difference of the tourniquet group was significantly larger than that of the non-tourniquet group (P < 0.05). However, 4 to 6 months after the surgery, no significant difference in knee circumference was found between the two groups (MD 0.14, 95% CI −0.02–0.31, P = 0.09, I² = 0%). The VAS score of the tourniquet group was higher than the non-tourniquet group on the 3rd and 5th days after surgery (P < 0.05). However, this difference was not significant (MD 0.31, 95% CI −0.05–0.66, P = 0.09, I² = 89%).

Conclusion

Results of this meta-analysis indicate that tourniquet application could increase the incidence of postoperative DVT and aggravate postoperative pain and swelling in the short term.

Level of evidence

Level III

Effect of tourniquet use on the risk of revision in total knee replacement surgery: an analysis of the National Joint Registry Data Set

OBJECTIVE

Tourniquet use in total knee replacement (TKR) is believed to improve the bone-cement interface by reducing bleeding, potentially prolonging implant survival. This study aimed to compare the risk of revision for primary cemented TKR performed with or without a tourniquet.

DESIGN

We analysed data from the National Joint Registry (NJR) for all primary cemented TKRs performed in England and Wales between April 2003 and December 2003. Kaplan-Meier plots and Cox regression were used to assess the influence of tourniquet use, age at time of surgery, sex and American Society of Anaesthesiologists (ASA) classification on risk of revision for all-causes.

RESULTS

Data were available for 16 974 cases of primary cemented TKR, of which 16 132 had surgery with a tourniquet and 842 had surgery without a tourniquet. At 10 years, 3.8% had undergone revision (95% CI 2.6% to 5.5%) in the no-tourniquet group and 3.1% in the tourniquet group (95% CI 2.8% to 3.4%). After adjusting for age at primary surgery, gender and primary ASA score, the HR for all-cause revision for cemented TKR without a tourniquet was 0.82 (95% CI 0.57 to 1.18).

CONCLUSIONS

We did not find evidence that using a tourniquet for primary cemented TKR offers a clinically important or statistically significant reduction in the risk of all-cause revision up to 13 years after surgery. Surgeons should consider this evidence when deciding whether to use a tourniquet for cemented TKR.

Effect of Tourniquet Use During Surgical Treatment of Open Fractures

BACKGROUND

We sought to evaluate whether tourniquet use, with the resultant ischemia and reperfusion, during surgical treatment of an open lower-extremity fracture was associated with an increased risk of complications.

METHODS

This is a retrospective cohort study of 1,351 patients who had an open lower-extremity fracture at or distal to the proximal aspect of the tibia and who participated in the FLOW (Fluid Lavage of Open Wounds) trial. The independent variable was intraoperative tourniquet use, and the primary outcome measures were adjudicated unplanned reoperation within 1 year of the injury and adjudicated nonoperative wound complications.

RESULTS

Unplanned reoperation and nonoperative wound complications were roughly even between the no-tourniquet (18.7% and 19.1%, respectively) and tourniquet groups (17.8% and 20.8%) (p = 0.78 and p = 0.52). Following matching, as determined by model interactions, tourniquet use was a significant predictor of unplanned reoperation in Gustilo Type-IIIA (odds ratio, 3.60; 95% confidence interval, 1.16 to 11.78) and IIIB fractures (odds ratio, 16.61; 95% confidence interval, 2.15 to 355.40).

CONCLUSIONS

The present study showed that tourniquet use did not influence the likelihood of complications following surgical treatment of an open lower-extremity fracture. However, in cases of severe open fractures, tourniquet use was associated with increased odds of unplanned reoperation; surgeons should be cautious with regard to tourniquet use in this setting.

LEVEL OF EVIDENCE

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

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.

Short-term outcomes of total knee arthroplasty performed with and without a tourniquet

INTRODUCTION

Not using a tourniquet could improve early postoperative pain, range of motion (ROM), length of stay (LOS), and thromboembolic risk in patients undergoing total knee arthroplasty (TKA). Our aim was to compare these factors, intraoperative blood loss, and gender-related outcomes in patients undergoing primary TKA with or without a tourniquet.

METHODS

We performed a retrospective cohort study of 97 patients undergoing TKA with or without tourniquet from 2018 to 2020. Revisions and bilateral TKAs were excluded. Blood loss was estimated using a validated formula. Postoperative pain was tested using the visual analogue scale (VAS). ROM and quadriceps lag were assessed by a physiotherapist on a postoperative day 2 and discharge. The index of suspicion for a thromboembolic event was defined as the number of embolic-related investigations ordered in the first 6 months post-surgery. The Shapiro-Wilk test was used to assess the distribution of the data, Mann-Whitney for the continuous variables, and Fischer's test for the categorical ones.

RESULTS AND DISCUSSION

There was a significant difference in blood loss. The non-tourniquet group lost on average 32% more blood (1291 mL vs. 878 mL, p<0.001 two-tailed). We found no difference in pain, ROM, LOS, and quadriceps lag on day 2 and at discharge. There was one thromboembolic event in the tourniquet group, but the thromboembolic index of suspicion did not differ (p=0.53). With tourniquet use, women had a significantly lower day 2 maximum flexion than men (71.56° vs. 84.67°, p=0.02). In this retrospective cohort study, the results suggest that tourniquet use is associated with lower blood loss and similar postoperative pain, range of motion, quadriceps lag, length of stay, and thromboembolic risk. There might be some differences between how men and women tolerate a tourniquet, with women having worse short-term outcomes compared to men.