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Anaspure O, Patel S, Baumann AN, Anastasio AT, Walley KC, Kelly JD, Lau BC. Examining the Evidence Regarding Smoking and Patient Outcomes for Isolated Meniscus Pathology: A Comprehensive Systematic Review and Meta-Analysis. Life (Basel) 2024; 14:584. [PMID: 38792605 PMCID: PMC11122235 DOI: 10.3390/life14050584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/19/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
Smoking is a well-known cause of impairment in wound healing and postoperative outcomes; however, its effects on treating meniscus issues remain unclear. This study assesses the relationship between smoking and meniscus treatment outcomes. PubMed, Scopus, Cochrane, and CINAHL were searched from inception to 24 December 2023. Inclusion criteria encompassed studies examining smoking's impact on patient outcomes regarding meniscus pathology. A secondary PubMed search targeted randomized controlled trials (RCTs) in the top ten orthopedic journals focusing on meniscus pathology and smoking as a demographic variable. Meta-analysis of six studies (n = 528) assessed meniscus failure rate based on smoking status. Eighteen observational studies (n = 8353 patients; 53.25% male; mean age: 51.35 ± 11.53 years; follow-up: 184.11 ± 117.34 months) were analyzed, covering meniscus repair, meniscectomy, allograft transplant, conservative care, and arthroscopy. Results showed four studies (36.36%) linked smoking with worse meniscus repair outcomes, while seven studies (63.64%) did not find significant associations. Meta-analysis from six studies showed no significant impact of smoking on repair failure (p = 0.118). Regarding meniscectomy, one study (33.33%) identified a significant association with smoking, but two did not. Only one (3.8%) of the RCTs in leading orthopedic journals included smoking as a factor. The evidence on smoking's effect on meniscus treatment is mixed, necessitating further investigation.
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Affiliation(s)
- Omkar Anaspure
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Shiv Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Anthony N. Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA;
| | - Albert T. Anastasio
- Department of Orthopedic Surgery, Duke University, Durham, NC 27710, USA; (A.T.A.); (B.C.L.)
| | - Kempland C. Walley
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI 48109, USA;
| | - John D. Kelly
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Brian C. Lau
- Department of Orthopedic Surgery, Duke University, Durham, NC 27710, USA; (A.T.A.); (B.C.L.)
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Zhang R, Chang SJ, Jing Y, Wang L, Chen CJ, Liu JT. Application of chitosan with different molecular weights in cartilage tissue engineering. Carbohydr Polym 2023; 314:120890. [PMID: 37173038 DOI: 10.1016/j.carbpol.2023.120890] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/27/2023] [Accepted: 04/04/2023] [Indexed: 05/15/2023]
Abstract
Cartilage tissue engineering involves the invention of novel implantable cartilage replacement materials to help heal cartilage injuries that do not heal themselves, aiming to overcome the shortcomings of current clinical cartilage treatments. Chitosan has been widely used in cartilage tissue engineering because of its similar structure to glycine aminoglycan, which is widely distributed in connective tissues. The molecular weight, as an important structural parameter of chitosan, affects not only the method of chitosan composite scaffold preparation but also the effect on cartilage tissue healing. Thus, this review identifies methods for the preparation of chitosan composite scaffolds with low, medium and high molecular weights, as well as a range of chitosan molecular weights appropriate for cartilage tissue repair, by summarizing the application of different molecular weights of chitosan in cartilage repair in recent years.
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Affiliation(s)
- Runjie Zhang
- Research Center for Materials Science and Opti-Electronic Technology, College of Materials Science and Opti-Electronic Technology, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Shwu Jen Chang
- Department of Biomedical Engineering, I-Shou University, Kaohsiung City 82445, Taiwan
| | - Yanzhen Jing
- Research Center for Materials Science and Opti-Electronic Technology, College of Materials Science and Opti-Electronic Technology, University of Chinese Academy of Sciences, Beijing 100049, China
| | - LiYuan Wang
- Research Center for Materials Science and Opti-Electronic Technology, College of Materials Science and Opti-Electronic Technology, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Ching-Jung Chen
- Research Center for Materials Science and Opti-Electronic Technology, School of Opto-Electronic Technology, University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Jen-Tsai Liu
- Research Center for Materials Science and Opti-Electronic Technology, College of Materials Science and Opti-Electronic Technology, University of Chinese Academy of Sciences, Beijing 100049, China.
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Vojdani S, Alex Ruberto R, Gazgalis A, Bonsignore-Opp L, Shah RP, John Cooper H, Geller JA. The temporal effects of variable tourniquet use on pain after total knee arthroplasty. Knee 2023; 43:184-191. [PMID: 37499424 DOI: 10.1016/j.knee.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/15/2023] [Accepted: 06/30/2023] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Saman Vojdani
- Columbia University Irving Medical Center, New York, NY, USA; Total Joint Specialists, Atlanta, GA, USA
| | - R Alex Ruberto
- Columbia University Irving Medical Center, New York, NY, USA
| | | | | | - Roshan P Shah
- Columbia University Irving Medical Center, New York, NY, USA
| | - H John Cooper
- Columbia University Irving Medical Center, New York, NY, USA
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Zhongyu X, Zhen Y, Bingqing G, Xintian K, Meifeng G, Jianda X. Intra-articular administration of adrenaline plus an irrigation pump system for visibility during the arthroscopic reconstruction of multiple knee ligaments without a tourniquet. Front Surg 2023; 10:1045839. [PMID: 37009621 PMCID: PMC10063814 DOI: 10.3389/fsurg.2023.1045839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/21/2023] [Indexed: 03/19/2023] Open
Abstract
ObjectiveMultiple ligament knee injuries (MLKIs) are rare but severe systemic trauma. Single surgery in the acute setting is preferred, although with an extended operation time. To avoid the complications associated with a tourniquet, we herein describe a method for visibility without a tourniquet: intra-articular administration of adrenaline plus an irrigation pump system.Study designThis is a cohort study with a level of evidence of 3.MethodsFrom April 2020 to February 2022, 19 patients with MLKIs were reviewed retrospectively. All patients got intra-articular administration of adrenaline plus an irrigation pump system for visibility without a tourniquet. The following parameters were assessed: visibility, range of motion, knee stability, visual analog scale (VAS) score, range of motion (ROM), Lysholm score, Tegner activity level, and International Knee Documentation Committee Subjective Knee Form (IKDC).ResultsAll patients were followed up for at least 6 months. At the latest follow-up, the mean VAS score, ROM, Lysholm score, and IKDC were 1.79 ± 0.86, 121.21 ± 10.96, 88.16 ± 5.21, and 88.53 ± 5.06, respectively. The average Tegner activity level decreased significantly from preinjury to postoperation (5.16 ± 0.83 vs. 3.11 ± 0.88, P < 0.001). Of the 19 patients, 17 (89.47%) had good knee function, while only two patients (10.53%) had asymptomatic knees with positive Lachman tests. A total of 17 patients (89.47%) had good or excellent visualization during arthroscopy. Of the 19 patients, three (15.79%) required an increased fluid pressure to achieve a clear operative view. Two patients converted to tourniquet inflation due to persistent intra-articular bleeding after using shavers.ConclusionsThe intra-articular administration of adrenaline plus an irrigation pump system is recommended as an alternative to a tourniquet to achieve a good visual field. Further evidence-based work with a larger sample is needed.
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Affiliation(s)
- Xia Zhongyu
- Department of Orthopaedics, Changzhou Traditional Chinese Medical Hospital, Affiliated to Nanjing University of Traditional Chinese Medicine, Changzhou, China
| | - Yu Zhen
- Department of Orthopedic, The Third Affiliated Hospital of Soochow University, First People's Hospital of Changzhou, Changzhou, China
| | - Guo Bingqing
- Department of Orthopaedics, Changzhou Traditional Chinese Medical Hospital, Affiliated to Nanjing University of Traditional Chinese Medicine, Changzhou, China
| | - Kong Xintian
- Department of Acupuncture, Changzhou Traditional Chinese Medical Hospital, Affiliated to Nanjing University of Traditional Chinese Medicine, Changzhou, China
| | - Guo Meifeng
- Department of Orthopaedics, Changzhou Traditional Chinese Medical Hospital, Affiliated to Nanjing University of Traditional Chinese Medicine, Changzhou, China
- Correspondence: Guo Meifeng Xu Jianda
| | - Xu Jianda
- Department of Orthopaedics, Changzhou Traditional Chinese Medical Hospital, Affiliated to Nanjing University of Traditional Chinese Medicine, Changzhou, China
- Correspondence: Guo Meifeng Xu Jianda
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Zaid HHG, Hua X, Chen B, Yang Q, Yang G, Cheng W. Tourniquet Use Improves Intraoperative Parameters, Leading to Similar Postoperative Outcomes Compared With No Tourniquet Use in Anterior Cruciate Ligament Reconstruction: A Prospective, Double-Blind, Randomized Clinical Trial. Arthroscopy 2023; 39:626-637.e3. [PMID: 36334854 DOI: 10.1016/j.arthro.2022.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/27/2022] [Accepted: 10/20/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To examine the effect of tourniquet use in arthroscopic anterior cruciate ligament reconstruction in terms of: (1) intraoperative visualization with operative time and consumption of sterile saline, and (2) intra- and postoperative blood loss, postoperative pain, opioid consumption, swelling, serum creatine phosphokinase (CPK) and hemoglobin (Hb) concentrations, clinical outcomes, and graft healing. METHODS In this prospective randomized clinical trial, patients were assigned to tourniquet inflation (tourniquet-up) or tourniquet deflation (tourniquet-down) groups. Primary outcomes were intraoperative visualization with operative time and sterile saline consumption. Secondary outcomes were intra- and postoperative blood loss, postoperative pain, opioid consumption, swelling, serum CPK, Hb concentration, subjective and objective functional scores, and graft healing. RESULTS Intraoperative visualization was satisfactory in 100 of 100 cases in the tourniquet-up group and 64 of 100 cases in the tourniquet-down group (P < .05). The mean operative time was 58.4 ± 5.7 minutes in the tourniquet-up group and 72.5 ± 8.6 minutes in the tourniquet-down group (P < .05). The mean sterile saline consumption was 6.4 ± 2.5 L in the tourniquet-up group and 8.7 ± 4.6 L in the tourniquet-down group (P < .05). The respective amounts of estimated intraoperative and postoperative blood loss were 95.3 ± 25.1 mL and 240.3 ± 44.5 mL in the tourniquet-up group and 230.2 ± 22.3 mL and 75.6 ± 15.3 mL in the tourniquet-down group (P < .05). Our results showed no significant difference in postoperative pain, opioid consumption, percentage of patients using opioids, swelling, mean serum CPK and Hb levels, subjective and objective functional scores, or graft healing (P > .05) between the 2 groups. CONCLUSIONS Tourniquet use during anterior cruciate ligament reconstruction significantly improves intraoperative visualization, shortens operative time, and decreases intraoperative sterile saline consumption and blood loss without serious adverse events or greater complication rates based on early postoperative outcomes. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Hamood H G Zaid
- First Affiliated Hospital of Xiamen University, Xiamen City, China; College of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou City, China
| | - Xu Hua
- First Affiliated Hospital of Xiamen University, Xiamen City, China
| | - Bingyi Chen
- First Affiliated Hospital of Xiamen University, Xiamen City, China
| | - Quanyuan Yang
- First Affiliated Hospital of Xiamen University, Xiamen City, China
| | - Guo Yang
- First Affiliated Hospital of Xiamen University, Xiamen City, China.
| | - Weinan Cheng
- First Affiliated Hospital of Xiamen University, Xiamen City, China.
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Sick leave after arthroscopic meniscus repair vs. arthroscopic partial meniscectomy. OSTEOARTHRITIS AND CARTILAGE OPEN 2023; 5:100340. [PMID: 36798736 PMCID: PMC9926294 DOI: 10.1016/j.ocarto.2023.100340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Objective To evaluate sick leave after meniscal repair vs arthroscopic partial meniscectomy (APM) and, for comparison, vs the general population. Method Using Swedish register data we included all employed persons aged 19-49 years in the general population of Skåne region and identified those having had meniscus repair or APM in the period of 2005-2012. We retrieved data on sick leave during 1 year before until 2 years after surgery. We used logistic regression to estimate the risk differences of being on sick leave and negative binomial model to analyze differences in the number of days on sick leave. Results We included 192 persons with meniscus repair, 2481 with APM, and 376 345 references without meniscus surgery. Of these, 55% of meniscus repair group, 43% of APM group had any sick leave in the 2-year period following the surgery, while 17% of the references were on sick leave in the corresponding period. The mean (SD) number of days of sick leave after meniscus repair was 55 (77) days and for APM 37 (86) days. Meniscus repair was associated with higher probability of sick leave compared to APM with an adjusted risk difference of 0.13 (95% CI 0.07-0.19). Conclusion Persons undergoing meniscus repair have more frequent and 37% longer periods of sick leave in the short term than persons undergoing APM. However, sick leave in the long-term warrant further attention as successful repair may be associated with less knee osteoarthritis development than APM.
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Visualization in arthroscopic meniscectomy- portal-site injection versus tourniquet inflation: A prospective, double-blinded, randomised controlled study. J Orthop 2021; 23:233-238. [PMID: 33613006 DOI: 10.1016/j.jor.2021.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/20/2020] [Accepted: 01/30/2021] [Indexed: 11/20/2022] Open
Abstract
Objectives Alternatives to tourniquets include portal-site epinephrine injections. This prospective, randomised-controlled, double-blinded study compared intraoperative visibility and safety of portal-site injections with tourniquets in arthroscopic meniscectomies. Methods Sixty eligible adults [16-55ys, excluding vascular/neuromuscular/systemic illnesses] were randomly/equally divided across 3 groups A (controls)-local portal injections; B-local injections with tourniquet; C-local and 1:200,000epinephrine injections. A single surgeon operated blinded to patient group. Intraoperative visibility, surgeon visual analogue score (VAS)and other details were recorded. Results Superior visibility [p = 0.003,p = 0.027] and VAS [p = 0.010,p = 0.042] were reported in groups B, C versus A, Visibility [p = 0.705; p = 0.805] and operating times [p = 0.05] were comparable between B and C. Conclusions Portal-site epinephrine injections emerged as tenable surrogates for tourniquets for clear visualization in arthroscopy.
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Wang J, Xu W, Lv J. Is It Better to Routinely Use Tourniquet for Knee Arthroscopic Surgery: A Systematic Review and Meta-analysis. J Knee Surg 2020; 33:866-874. [PMID: 31064020 DOI: 10.1055/s-0039-1688555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of tourniquet in knee arthroscopic surgery is a routine technique and provides convenience for the operation. However, the adverse effects caused by tourniquet during the operation are noticed by more and more researchers. The purpose of our study was to perform a systematic review and meta-analysis to assess the effects of tourniquet use in knee arthroscopy. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we searched databases like PubMed, Cochrane library, EMBASE, and Web of Science from inception of the database up to November 20, 2018, using the keywords " anterior cruciate ligament," "meniscectomy," "arthrocopy," etc. to identify randomized clinical trials. A total of 16 randomized controlled trials involving 1,132 participants fulfilled the inclusion criteria with 582 patients in tourniquet group and 550 patients in nontourniquet group. Compared with tourniquet group, nontourniquet group had less postoperative blood loss and less consumption of analgesic. There was no significant difference between the two groups in intraoperatively arthroscopic visualization, postoperative pain score, postoperative quadriceps muscle strength, and operation time. Our study suggested that compared with tourniquet use, arthroscopic surgery of the knee without tourniquet did not appear to have any disadvantage, and the current evidence was more inclined not to use tourniquet as a routine procedure during the knee arthroscopic surgery.
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Affiliation(s)
- Jinyou Wang
- Department of Orthopaedics, Jilin University Sino-Japanese Friendship Hospital, Changchun, Jilin, China
| | - Wennan Xu
- Department of Orthopaedics, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jiayin Lv
- Department of Orthopaedics, Jilin University Sino-Japanese Friendship Hospital, Changchun, Jilin, China
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Ahn JH, Park D, Park YT, Park J, Kim YC. What should we be careful of ankle arthroscopy? J Orthop Surg (Hong Kong) 2020; 27:2309499019862502. [PMID: 31359846 DOI: 10.1177/2309499019862502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Ankle arthroscopy has been used as a standard tool by foot and ankle surgeons. To overcome the narrowness of ankle joint, a noninvasive distraction technique is used for the successful visualization in ankle arthroscopy. The aim of this study was to investigate the incidence and type of complications associated with ankle arthroscopy using a noninvasive distraction technique and to report a troublesome complication. METHODS We reviewed 514 patients' charts from 2003 to 2011. The same noninvasive distraction technique was used. Patients' demography, duration of follow-up, diagnoses, procedures, and complications related to ankle arthroscopy were analyzed. RESULTS There were 388 male and 126 female; mean age was 37.2 years; mean follow-up duration was 33 months. The diagnoses were osteochondral lesion of talus, chronic ankle instability, anterolateral soft tissue impingement syndrome, and anterior bony impingement. We performed arthroscopic synovectomy, osteochondral procedure, bony spur excision, and loose body removal. The mean time of arthroscopic procedure was 47 min. There were neurologic complications (eight cases), skin necrosis of posterior thigh (three cases), instrument breakage (two cases), and superficial wound infection (one case). All complications were well resolved. The total duration of distraction plus tourniquet inflation exceeded 120 min in the three cases of skin necrosis. Skin necrosis was deemed to be resulted from the long tourniquet time. CONCLUSION The noninvasive distraction technique is safe and effective for ankle arthroscopy. However, the distraction plus tourniquet requires attention because it can cause high pressure on posterior thigh resulting in soft tissue injury.
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Affiliation(s)
- Jae Hoon Ahn
- 1 Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dojoon Park
- 2 Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Taek Park
- 2 Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joonyoung Park
- 2 Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon-Chung Kim
- 2 Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Ajnin S, Fernandes R. Reduced length of stay and faster recovery after total knee arthroplasty without the use of tourniquet. J Clin Orthop Trauma 2020; 11:129-132. [PMID: 32002000 PMCID: PMC6985009 DOI: 10.1016/j.jcot.2019.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/06/2019] [Accepted: 08/23/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is commonly performed using tourniquet despite being associated with several recognised complications that may affect patient's post-operative recovery and early rehabilitation. In this study we investigate whether or not use of a tourniquet during TKA was associated with shorter length of stay, faster recovery and lesser complications. METHODS 29 patients, who underwent bilateral sequential TKA, had their first TKA under tourniquet and the second TKA 15 (11-32) months later without tourniquet.All operations were performed by the first author using the same technique and instrumentation with the same early rehabilitation protocol. All patients were followed prospectively for a minimum of 8 months.All patients had the following parameters measured which included surgical time, length of stay, post-operative pain using Visual analogue score (VAS), calf circumference, drop in haemoglobin, haematocrit level, oxford knee score (OKS), and range of motion (ROM). RESULTS TKA performed without the use of tourniquet had significantly shorter Length of hospital stay (3.6 vs 4.4, P < 0.05), significantly less pain on day 2 (1 vs 2; P < 0.05) and significantly smaller increase in calf circumference on day 2 (1.2 cm vs 2.3 cm; P < 0.05). Postoperative calf circumference increase of less than 2 cm in TKA without tourniquet was associated with shorter length of stay when compared with increase of more than 2 cm in TKA with tourniquet 2.9 days (SD 0.6) versus 3.9 days (SD 0.8) P < 0.05.ROM and OKS were significantly better in TKA without tourniquet at 6 weeks but no difference at 8 months. CONCLUSIONS TKA done without tourniquet was associated with shorter length of stay, lesser pain and swelling, in addition to improved range of motion in the early post-operative period.
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Affiliation(s)
- Sheldon S Lin
- Department of Orthopaedics, Rutgers New Jersey School of Medicine, Newark, New Jersey
| | - Omkar Baxi
- Department of Orthopaedics, Rutgers New Jersey School of Medicine, Newark, New Jersey
| | - Michael Yeranosian
- Department of Orthopaedics, Rutgers New Jersey School of Medicine, Newark, New Jersey
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Kuo LT, Yu PA, Chen CL, Hsu WH, Chi CC. Tourniquet use in arthroscopic anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials. BMC Musculoskelet Disord 2017; 18:358. [PMID: 28830402 PMCID: PMC5567632 DOI: 10.1186/s12891-017-1722-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the effects of tourniquet use in arthroscopic anterior cruciate ligament (ACL) reconstruction surgery. METHODS We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) that compared surgical outcomes following tourniquet use against non-tourniquet use during ACL reconstruction surgery. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for relevant RCTs. We used the Cochrane Collaboration's tool to assess the risk of bias of included RCTs, and performed a random-effects meta-analysis in calculating the pooled risk estimates. The primary outcomes was postoperative pain measured by visual analogue scale, verbal rating scale, or required morphine dose. The secondary outcomes were blood loss in drainage, operative time, muscle strength, and calf and thigh girth. RESULTS We included 5 RCTs with 226 participants (116 in the tourniquet group and 110 in the non-tourniquet group). Postoperative pain and morphine doses were not significantly different between the two groups. Compared to the non-tourniquet group, the tourniquet group had a significantly increased blood loss in the drain (mean difference: 94.40 ml; 95% CI 3.65-185.14; P = 0.04). No significant differences in the operative time and muscle strength were found between the two groups. Tourniquet use was associated with a greater decrease in thigh girth but not in calf girth. CONCLUSIONS The current evidence shows that compared to tourniquet use, ACL reconstruction surgery without tourniquet does not appear to have any major disadvantages and does not prolong operation time. There might be less drain blood loss associated with tourniquet use, though drains are no longer routinely used in ACL reconstruction surgery.
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Affiliation(s)
- Liang-Tseng Kuo
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, 6, Sec West, Chia-Pu Rd, Puzih, Chiayi, 61363, Taiwan.,Centre for Evidence-Based Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Pei-An Yu
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, 6, Sec West, Chia-Pu Rd, Puzih, Chiayi, 61363, Taiwan
| | - Chi-Lung Chen
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, 6, Sec West, Chia-Pu Rd, Puzih, Chiayi, 61363, Taiwan
| | - Wei-Hsiu Hsu
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, 6, Sec West, Chia-Pu Rd, Puzih, Chiayi, 61363, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ching-Chi Chi
- Centre for Evidence-Based Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Department of Dermatology, Chang Gung Memorial Hospital, Linkou, 5, Fuxing St, Guishan Dist, Taoyuan, 33305, Taiwan.
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Dimnjaković D, Hrabač P, Bojanić I. Value of Tourniquet Use in Anterior Ankle Arthroscopy: A Randomized Controlled Trial. Foot Ankle Int 2017; 38:716-722. [PMID: 28399633 DOI: 10.1177/1071100717702461] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A tourniquet is usually used during anterior ankle arthroscopy to allow for improved visibility and reduced operation time. However, this has not been demonstrated to be true in clinical studies on knee arthroscopy, while limited tourniquet time has been described as a possible factor to lower the complication rate of ankle arthroscopy. The purpose of this randomized controlled trial was to examine the effect of tourniquet use on arthroscopic visualization, operative time, postoperative intra-articular bleeding, postoperative pain scores, and outcome of anterior ankle arthroscopy. METHODS A consecutive series of 50 patients who were scheduled for anterior ankle arthroscopy were randomized to have the surgery done either without the tourniquet inflated (25 patients) or with the tourniquet inflated (25 patients). The patients were evaluated by the course of the surgery, postoperative intra-articular bleeding, and pain during the early postoperative period, and subjective and objective functional scores were used to evaluate the condition of the ankle before and 3 and 6 months after the surgery. Forty-nine patients were present at the final follow-up, 6 months after the surgery. RESULTS The results between the groups were comparable regarding the duration of the operative procedure, consumption of sterile saline, visualization, and functional scores. A notable difference between the groups in favor of the nontourniquet group was present regarding postoperative bleeding but was not statistically significant. A statistically significant difference in favor of the nontourniquet group was found regarding postoperative pain during several days in the early postoperative period. CONCLUSION Our study showed that anterior ankle arthroscopy was performed adequately without the use of a tourniquet and that it had the same operative course as cases in which the tourniquet was used and functional outcomes that were not worse than cases in which the tourniquet was used. LEVEL OF EVIDENCE Level I, prospective randomized controlled trial.
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Affiliation(s)
- Damjan Dimnjaković
- 1 Department of Orthopedic Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Pero Hrabač
- 2 Croatian Institute for Brain Research, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Bojanić
- 1 Department of Orthopedic Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
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Reda W, ElGuindy AMF, Zahry G, Faggal MS, Karim MA. Anterior cruciate ligament reconstruction; is a tourniquet necessary? A randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2016; 24:2948-2952. [PMID: 25786826 DOI: 10.1007/s00167-015-3582-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE This work aimed at studying the effect of tourniquet use on surgical performance and peri-operative outcomes of anatomic single-bundle ACL reconstruction. METHODS Eighty-four patients undergoing ACL surgery were randomized into two groups: the tourniquet (A) group and the non-tourniquet (B) group. Post-operative pain, need for analgesics, the volume of blood obtained in the drain, girth diameter changes in the thigh and calf, muscle strength and amount of haemarthrosis were used as outcome measures to compare the two groups. RESULTS Fifty-eight patients were available for analysis. In the A group, the degree of pain and need to analgesics was significantly higher at 4 and 10 h. The volume measured in the surgical drain, at 24 h post-operative, was higher in the A group (p = 0.001). The calf and thigh girth diameters at 2 weeks showed a highly significant girth difference between the two groups (p = 0.001). CONCLUSION This study showed that tourniquet use in ACL reconstruction increases immediate post-operative symptoms of pain and haemarthrosis and that the effects on muscle strength are only temporary. The tourniquet can be replaced by using of a mixture of morphine and adrenaline with no interference with the quality of visibility, nor operative time. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Walid Reda
- Department of Orthopedic Surgery, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Gomoa Zahry
- Department of Anaesthesia, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona Selim Faggal
- Department of Physical Therapy for Musculoskeletal Disorders, Faculty of Physical Therapy, Beni Suef University, Beni Suef, Egypt
| | - Mahmoud Abdel Karim
- Department of Orthopedic Surgery, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Abstract
INTRODUCTION The tourniquet is a surgical device composed of a round pneumatic cuff in which air at high pressure can be inflated with an automatic programmable pump to avoid bleeding and technical impediment. SOURCES OF DATA Comprehensive searches of Medline, Cochrane and Google Scholar databases were performed for studies regarding tourniquet application in arthroscopic and open surgery of the knee. The methodological quality of each study was evaluated using the Coleman methodology score (CMS). AREAS OF AGREEMENT The use of a tourniquet does not lead to significant increase in the risk of major complications, and there is no difference in clinical outcome in the medium term. The inflated cuff does prevent intraoperative blood loss, but hidden blood loss is not avoided completely. There is a statistically significantly higher occurrence of deep vein thrombosis in patients who undergo surgery with tourniquet, but the clinical relevance of this finding is uncertain. AREAS OF CONTROVERSY The heterogeneity in terms of inflating pressure and duration of application of tourniquet in the single studies makes it very difficult to compare the outcomes of different investigations to draw definitive conclusions. GROWING POINTS Standardization of pressure and application time of the cuff could allow a comparison of the data reported by the trials. Better study methodology should be also implemented since the mean CMS considering all the reviewed articles was 57.6 of 100. RESEARCH More and better designed studies are needed to produce clear guidelines to standardize the use of tourniquet in knee procedures.
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Affiliation(s)
- Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Biagio Zampogna
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Guglielmo Torre
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Salerno 84081, Italy Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
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Ejaz A, Laursen AC, Kappel A, Laursen MB, Jakobsen T, Rasmussen S, Nielsen PT. Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop 2014; 85:422-6. [PMID: 24954487 PMCID: PMC4105775 DOI: 10.3109/17453674.2014.931197] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Tourniquet application is still a common practice in total knee arthroplasty (TKA) surgery despite being associated with several adverse effects. We evaluated the effects of tourniquet use on functional and clinical outcome and on knee range of motion (ROM). PATIENTS AND METHODS 70 patients who underwent TKA were randomized into a tourniquet group (n = 35) and a non-tourniquet group (n = 35). All operations were performed by the same surgeon and follow-up was for 1 year. Primary outcomes were functional and clinical outcomes, as evaluated by KOOS and knee ROM. Secondary outcomes were intraoperative blood loss, surgical time and visibility, postoperative pain, analgesic consumption, and transfusion requirements. RESULTS Patients in the non-tourniquet group showed a better outcome in all KOOS subscores and better early knee ROM from surgery to week 8. No difference was detected at the 6- and 12-month follow-ups. Postoperative pain and analgesic consumption were less when a tourniquet was not used. Surgical time and visibility were similar between groups. Intraoperative blood loss was greater when not using a tourniquet, but no postoperative transfusions were required. INTERPRETATION This study shows that TKA without the use of a tourniquet results in faster recovery in terms of better functional outcome and improved knee ROM. Furthermore, reduced pain and analgesic use were registered and no intraoperative difficulties were encountered.
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Affiliation(s)
- Ashir Ejaz
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Anders C Laursen
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Mogens B Laursen
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Thomas Jakobsen
- Department of Orthopedic Surgery,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Sten Rasmussen
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Farr J, Jaggers R, Lewis H, Plackis A, Sim SB, Sherman SL. Evidence-based approach of treatment options for postoperative knee pain. PHYSICIAN SPORTSMED 2014; 42:58-70. [PMID: 24875973 DOI: 10.3810/psm.2014.05.2058] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Optimal pain management is critical after knee surgery to avoid adverse events and to improve surgical outcomes. Pain may affect surgical outcomes by contributing to limitations in range of motion, strength, and functional recovery. The causes of postoperative pain are multifactorial; therefore, an appropriate pain management strategy must take into account preoperative, intraoperative, and postoperative factors to create a comprehensive and individualized plan for the patient. Preoperative assessment includes management of patient expectations, recognition of conditions and early counseling for high-risk patients (ie, opioid dependence, psychiatric comorbidities), and use of preemptive analgesia techniques (ie, preoperative IV medications, peripheral nerve blocks, incisional field blocks). Intraoperative strategies include meticulous surgical technique, limiting the use of tourniquets (ie, duration and pressure), and using preventive analgesia methods (ie, postoperative field block, continuous nerve catheters, intra-articular injection). Postoperative analgesia may be facilitated by cryotherapy, early mobilization, bracing, and rehabilitation. Certain modalities (ie, continuous passive motion devices, transcutaneous electrical nerve stimulation units, iontophoresis) may be important adjuncts in the perioperative period as well. There may be an evolving role for alternative medicine strategies. Early recognition and treatment of exaggerated postoperative pain responses may mitigate the effects of complex regional pain syndrome or the development of chronic pain.
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Affiliation(s)
- Jack Farr
- Cartilage Restoration Center of Indiana, Greenwood, IN
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Use of dextran sulfate in tourniquet-induced skeletal muscle reperfusion injury. J Surg Res 2014; 187:150-61. [DOI: 10.1016/j.jss.2013.10.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 09/23/2013] [Accepted: 10/08/2013] [Indexed: 12/11/2022]
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