Total Knee Arthroplasty Without the Use of a Tourniquet

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.

Much ado about nothing: the effect of tourniquet time on an accelerated rehabilitation programme following total knee replacement (TKR)

BACKGROUND

The WHO includes osteoarthritis as a disease of priority, owing to its significant impact on quality of life, and globally increasing prevalence. Hospital budgets are under pressure to ration knee replacements and shorten inpatient stays. Prolonged tourniquet application has been hypothesised to extend recovery through pain and reduced mobility.

PATIENTS AND METHODS

A total of 123 elective total knee replacements meeting inclusion criteria took place from July 2015 to October 2017 at the Royal Free Hospital. Cases were standardised by method of TKR, implant, physiotherapy and analgesic regime according to the trust Enhanced Recovery after Surgery pathway. Tourniquet time was compared to length-of-stay post-operatively and total opioid analgesia requirement over 24 h.

RESULTS

Median tourniquet time overall was 74 min and was decreased year-on-year from 108 to 60 min (p = 0.000). Inpatient median length-of-stay was 5 days and did not decrease (p = 0.667). Increased tourniquet time was not associated with longer length-of-stay but in fact shorter (p = 0.03199), likely due to this confounding temporal trend. Increased tourniquet time was not associated with increased opioid requirement (p = 0.78591). No association was found between tourniquet time and other complications including DVT and infection.

CONCLUSIONS

Our study finds no evidence that reductions in tourniquet time in TKR improve recovery including length-of-stay or opioid requirement. This clinical data is expected to augment PROMs collected by the National Joint Registry.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic study, Level I.