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

Pseudoaneurysm of the superolateral genicular artery following ACL outside-in reconstruction

A female underwent arthroscopic anterior cruciate ligament reconstruction (ACLR) via an outside-in drilling technique. At 4 weeks after surgery, she presented with a pulsatile painful mass on the lateral femoral condyle. Imaging confirmed a superolateral genicular artery pseudoaneurysm. Thrombin injections were administered twice, resulting in reduced size and minimal pain. This case emphasises the rare occurrence of pseudoaneurysms post-ACLR and highlights the importance of early detection and intervention for vascular complications. Although debated, we suggest tourniquet deflation before closure to facilitate identification and management of vascular issues. This report contributes valuable insights into managing pseudoaneurysms following ACLR.

Tourniquet Use in Extremity-Based Microsurgery

BACKGROUND

 The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications.

METHODS

 A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results.

RESULTS

 A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions.

CONCLUSION

 Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

A Practical Approach for Ischemic Preconditioning Intervention in Sports: A Pilot Study for Cuff Thigh Occlusion Pressure Estimation Based on Systolic Blood Pressure

For the ischemic preconditioning (IPC) intervention, the accuracy of the protocol is paramount for mediating its possible ergogenic effects. However, the lack of standardization and widespread use of arbitrary cuff pressures (ranging from 130 to >300 mmHg) have been predominantly observed, potentially affecting the results and compromising the reproducibility of findings. Thus, the purpose of this study was to determine an appropriate cuff pressure during IPC. Seventeen healthy male participants were enrolled in the study. Anthropometric measurements were initially conducted, followed by systolic and diastolic blood pressure measurements. Subsequently, we determined the individual thigh occlusion pressure (TOP) for the right leg using a hand-held Doppler device. Based on these findings, we developed an estimation equation for TOP, considering the current brachial systolic blood pressure (SBP) values. We then conducted a retrospective analysis of its capacity to mediate occlusion. We observed the ability to estimate TOP using the equation (p = 0.01; ES: 0.86), presenting ~6% superiority in absolute values for occlusion compared to direct measurement (TOP equation: 169.9 ± 9.1; TOP direct measured: 161.2 ± 11.1). However, TOP estimation was insufficient to produce complete occlusion in two out of 17 subjects (11.8%). In conclusion, the estimation of TOP incorporating SBP values may offer a valid and practical means for cuff administration during IPC protocols with potential to minimize adverse effects and maximize its positive effects.

Low albumin-to-fibrinogen ratio predicts adverse clinical outcomes after primary total joint arthroplasty: A retrospective observational investigation

Nutritional markers for adverse clinical outcomes following total joint arthroplasty (TJA) remain controversial. This study attempted to explore the validity of the albumin-to-fibrinogen ratio (AFR) in nutritional assessment and assess its predictive value for adverse postoperative outcomes in patients receiving TJA. 2137 patients who underwent primary TJA between January 2016 and June 2021 were screened. We performed receiver operating characteristic curves and area under the curve (AUC) to assess predictive value and establish optimal thresholds. Multivariate regression models were then used to assess potential associations between AFR and adverse postoperative outcomes. AFR might predict postoperative deep surgical site infections (AUC = 0.699, P = .023). The optimal threshold for wound complications, determined by the Youden index, was 12.96. Compared with patients with reduced AFR, patients with high AFR exhibited an enhanced risk of adverse postoperative outcomes (adjusted OR: 4.010-8.832, all P < .05). Using multivariate Cox regression analysis, we further confirmed a higher risk of adverse postoperative outcomes in patients with low AFR (adjusted HR: 3.733-7.335, all P < .05). Reduced preoperative AFR markedly enhanced adverse postoperative outcomes. Hence, AFR may serve as a potential biomarker for nutritional assessment, and may predict postoperative wound complications following primary TJA.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Higher Tissue Concentrations of Vancomycin Achieved With Low-Dose Intraosseous Injection Versus Intravenous Despite Limited Tourniquet Duration in Primary Total Knee Arthroplasty: A Randomized Trial

BACKGROUND

Vancomycin use has been suggested in high risk patients undergoing total knee arthroplasty (TKA). Previous literature has shown that a lower dose (500 mg) of vancomycin given by intraosseous regional administration (IORA) achieves tissue concentrations 4-10 times higher than intravenous (IV) administration. There is increasing interest in performing TKA with limited tourniquet inflation time. The purpose of this study is to evaluate whether IORA of vancomycin can achieve effective tissue concentrations with limited tourniquet inflation time.

METHODS

Based on prior power calculations, 24 patients undergoing primary TKA were randomized into 2 groups. Group IV-Systemic received weight-based (15 mg/kg) vancomycin with the tourniquet inflated for cementation only. Group IORA received 500 mg vancomycin via IORA after tourniquet inflation which remained inflated for 10 minutes, then reinflated for cementation only. Vancomycin concentrations from tissue, serum, and drain fluid were compared between the 2 groups.

RESULTS

Median vancomycin concentrations in tissue were significantly higher (5-15 times) at all time points in the IORA group. Concentrations in fat at the time of wound closure, after the tourniquet had been deflated for most of the procedure, were 5.2 μg/g in Group IV-Systemic and 33.1 μg/g in Group IORA (P < .001). Median bone concentrations taken just prior to cementation were 7.9 μg/g in Group IV-Systemic and 21.8 μg/g in Group IORA (P = .006). There were no complications related to IORA.

CONCLUSION

For surgeons who wish to limit tourniquet time and when indicated to use vancomycin, low-dose vancomycin IORA achieves tissue concentrations 5-15 times higher than those achieved by IV administration.

LEVEL OF EVIDENCE

Level 1 therapeutic randomized trial.

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.

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.

The impact of tourniquet on tibial bone cement penetration in different zones in primary total knee arthroplasty: a meta-analysis

Background

Cement mantle penetration and the cement–bone interface strength were critical to a successful primary total knee arthroplasty (TKA). It remained unclear whether decreased blood and fat in the cancellous bone achieved with the use of a tourniquet increases tibial cement mantle penetration in different zones on AP and lateral view in TKA according to criteria defined by the Knee Society Scoring System (KSS). The purpose of this study was to determine whether tourniquet use influences tibial cement mantle penetration in different zones on AP and lateral view in TKA according to KSS.

Methods

We conducted a meta-analysis to identify studies involving the impact of tourniquet use and no tourniquet use on tibial bone cement penetration in primary TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, VIP, Wanfang database, up to January 2021. Finally, we identified 1231 patients (1231 knees) assessed in twelve studies.

Results

Tourniquet use increases the cumulative cement mantle penetration (P < 0.00001), mean cement mantle penetration (P = 0.004), and cement mantle in zone 3(P < 0.0001) on AP view. However, there were no significant differences in cement mantle in zone 1(P = 0.5), zone 2(P =0 .54), zone 4(P = 0.07) on AP view, and zone 1(P = 0.32), zone 2(P = 0.38) on lateral view between two groups. There were also no significant differences in length of surgery(P = 0.7), change in hemoglobin(P = 0.4), transfusion rates(P = 0.47), and complications such as muscular calf vein thrombosis(P = 0.21), superficial infection (P = 0.72), and deep vein thrombosis (P = 0.66) between two groups.

Conclusion

The application of a tourniquet increases the thickness of the tibial bone cement penetration—the increase in the thickness of bone cement penetration mainly located in zone 3 on the anteroposterior (AP) view.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Effects of tourniquet application on enhanced recovery after surgery (ERAS) and ischemia-reperfusion post-total knee arthroplasty: Full- versus second half-course application

PURPOSE

Pneumatic tourniquets are used in total knee arthroplasty (TKA) for surgical field visualization and improved cementation; however, their use is controversial. This study aimed to assess the effects of tourniquet application on enhanced recovery post-TKA.

METHODS

A prospective randomized single-blinded trial assessed tourniquet's effects on postoperative pain, swelling, and early outcome in TKA. One-hundred and two patients with knee osteoarthritis were randomized to full-course (FC) and second half-course (SHC) application (n = 51/group). Tumor necrosis factor-alpha (TNF-α), C-C motif chemokine ligand 2(CCL-2), pentraxin-3 (PTX-3), prostaglandin E-2 (PGE-2), superoxide dismutase-1 (SOD-1), and myoglobin (Mb) were assessed by enzyme-linked immunosorbent assay, while the visual analog scale (VAS), range of motion (ROM), and thigh circumference growth rate were recorded.

RESULTS

Average tourniquet duration significantly differed between the SHC (37.5 ± 5.1 min) and FC (66.4 ± 7.2 min) groups (p < 0.01); VAS and thigh circumference growth rate in the SHC group were much lower compared with the FC group, while ROM was higher within 48 h of tourniquet removal (p < 0.01). Blood TNF-α, PTX3, CCL2, PGE2, SOD-1, and Mb were lower in the SHC group than the FC group (p < 0.01). Additionally, intraoperative blood loss was significantly elevated in the SHC group than the FC group (p < 0.01), with lower postoperative blood loss in the drain (p = 0.001). Postoperative drainage volume was reduced in the SHC group compared with the FC group (p < 0.01); five and two patients in the FC and SHC groups required blood transfusion, respectively (p = 0.025). Hospital stay tended to be shorter in the SHC group (p = 0.023), and no tourniquet-related complications were recorded.

CONCLUSION

Improved therapeutic outcome was observed in the SHC group, indicating patients should routinely undergo TKA with SHC tourniquet application.

Proprioceptive training on the recovery of total knee arthroplasty patients: A meta-analysis protocol of randomized controlled trial

BACKGROUND

Total knee arthroplasty is a common surgery for end-stage of knee osteoarthritis. Proprioceptive training has become an important part in athletes training programmes in different sports. However, the effects of proprioceptive training on the recovery of total knee arthroplasty were unknown. This meta-analysis, with its comprehensive and rigorous methodology, will provide better insight into this problem.

METHODS AND ANALYSIS

Electronic databases including PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI) database, Wanfang Database and Chinese Biomedical Literature Database (CBM) were searched from its inception to October 21, 2020. We only included proprioceptive training vs placebo in patients after total knee arthroplasty and pooled results were summarized by STATA 12.0 software. Two researchers independently selected the study and assessed the quality of the included studies. The heterogeneity was measured by I2 tests (I2 < 50 indicates little heterogeneity, I2 ≥ 50 indicates high heterogeneity). Publication bias was ruled out by funnel plot and statistically assessed by Beggs test (P > .05 as no publication bias).

RESULTS

Results will be published in relevant peer-reviewed journals.

CONCLUSION

Our study aims to systematically present the clinical effects of proprioceptive training after total knee arthroplasty patients, which will be provide clinical guidance for total knee arthroplasty patients.

Enhanced recovery principles applied to revision hip and knee arthroplasty leads to better patient outcomes

Aims

There is very little published literature on Enhanced Recovery Principles (ERP) used in primary joint replacements applied to revision hip and knee arthroplasty (rTHA, rTKA).

Methods

Retrospective series of 268 rTHA and rTKA surgeries from 2010 -2018, treated with ERP, focusing on multimodal pain management, blood management and early functional recovery.

Results

No patients from the latest cohort required readmission within 6 weeks. Only 20 patients (7.5%) required a blood transfusion. Surgical site local anaesthetic infiltration was associated with lower PCA use in aseptic rTHA and rTKA (p<0.001; p<0.001). Revisions for infection had a longer length of stay (LOS) and increased PCA usage in both rTHA (6.5 vs. 5.2 days) and rTKA (10.1 vs. 5.3 days), similar to our previous study.¹ Use of an intra-articular catheter for analgesia in rTKA showed reduced PCA use. Tourniquets were not beneficial for blood loss in rTKA and had greater PCA use post-operatively (p<0.001).

Conclusion

The application of ERP to revision THA and TKA surgery is safe and effective.

Comparison of Postoperative Effects between Medial Pivot Prosthesis and Posterior Stabilized Prosthesis

Objective

To compare the postoperative inflammation and pain response between medial pivot (MP) and posterior stabilized (PS) prostheses among total knee arthroplasty (TKA) patients.

Methods

A prospective cohort study was conducted from January 2019 to May 2019 at the Affiliated Hospital of Qingdao University. The study included patients diagnosed with stage III or IV Kellgren–Lawrence knee osteoarthritis (KOA) who had failed conservative treatment, had undergone no previous knee surgeries, had varus substantial deformities (11°–20° deviation), and had received their first unilateral TKA. A total of 109 patients who underwent PS prosthesis TKA and 98 patients who underwent MP prosthesis TKA were continuously enrolled. Inflammation biomarkers, such as leukocyte (white blood cells), erythrocyte sedimentation rate (ESR), and C‐reactive protein (CRP), together with hemoglobin (Hb), the visual analog pain score (VAS) and range of motion (ROM) were compared between the two groups. The Student t‐test was applied to analyze continuous parameters, and the χ²‐test was used for categorical parameters. The linear mixed model was used for the repeated measurement data from the follow‐up visits. Multivariate backward logistic and linear regression models were used to determine the factors potentially influencing prostheses and VAS scores.

Results

All these enrolled patients were followed up at 2, 4, 7, and 30 days after TKA. There were no significant differences between the PS group and the MP group in body mass index (BMI), gender, laterality, usage of nonsteroidal anti‐inflammatory drugs (NSAIDs) and opioids, and drain tube extubation time (P > 0.05). Compared with the PS group, the MP group were older (67.5 years vs 65.4 years), and had a higher mid‐vastus approach rate (67.3% vs 26.6%), a shorter tourniquet duration (68.3 ± 10.2 h vs 73.9 ± 11.2 h), a larger prosthetic pad (10.8 ± 1.2 mm vs 10.4 ± 1.2 mm), and a lower drain tube diversion volume (187.6 ± 119.3 mL vs 234.0 ± 155.7 mL). In the linear mixed model, MP prostheses had less CRP and ESR elevation and less Hb decrease than PS prostheses (P for group × time < 0.001). There were no significant differences in the changing trends between MP and PS prostheses by time for VAS scores and ROM. In the multivariate logistic regression model, MP prostheses showed significant differences compared with PS prostheses in treatment approach (odds ratio [OR] = 3.371, 95% confidence interval [CI]: 1.953–7.127; P < 0.001), ultrasound treatment start time (OR = 2.669, 95% CI: 1.385–5.141; P = 0.003), and tourniquet duration (OR = 0.954, 95% CI: 0.925–0.984; P = 0.003). Higher VAS scores on the second day postoperatively were related to high VAS scores preoperatively, use of opioids, high drain tube diversion, long tourniquet duration, and long drain tube extubation (P < 0.05), respectively.

Conclusion

The MP prostheses showed potential advantages compared with PS prostheses in TKA in inflammatory responses.

Tibial cement mantle thickness is not affected by tourniquetless total knee arthroplasty when performed with tranexamic acid

PURPOSE

Evidence exists that tourniquet use leads to increased cement penetration in total knee arthroplasty (TKA) due to decreased blood and fat in the bone during cementation. The use of tranexamic acid (TXA) has led to decreased blood loss and transfusion rates. The purpose of this study was to determine if the use of a tourniquet while utilising modern TXA protocols affects the tibial cement mantle penetration.

METHODS

140 patients who underwent primary TKA with and without a tourniquet (70 in each group) were retrospectively reviewed. All patients received a standard TXA protocol. The primary outcome measure was cumulative depth of cement mantle penetration of the tibial plateau on post-operative radiographs. Secondary outcome measures included post-operative change in haemoglobin and hematocrit levels, blood loss, and transfusion rates.

RESULTS

There was no significant difference in age, sex, or pre-operative haemoglobin or hematocrit levels between groups. Tourniquet use resulted in significantly lower blood loss (100.0 mL versus 154.7 mL, p < 0.001), and significantly reduced drop in haemoglobin (1.8 g/dL vs 2.5 g/dL, p < 0.001) and hematocrit (5.7% vs 7.4%, p = 0.04) levels. However, depth of tibial cement mantle penetration did not differ between the tourniquet group (15.3 mm) and non-tourniquet group (15.0 mm, p value n.s.). No patient in either group required a blood transfusion.

CONCLUSIONS

Tourniquet use in primary TKA results in decreased blood loss and less change in pre-operative vs post-operative haemoglobin and hematocrit levels. However, with the use of TXA, not using a tourniquet resulted in similar cement mantle penetration around the tibial component as with a tourniquet.

The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: a meta-analysis

Background

The tourniquet is a common medical instrument used in total knee arthroplasty (TKA). However, there has always been a debate about the use of a tourniquet and there is no published meta-analysis to study the effects of a tourniquet on blood loss in primary TKA for patients with osteoarthritis.

Methods

We performed a literature review on high-quality clinical studies to determine the effects of using a tourniquet or not on blood loss in cemented TKA. PubMed, Web of Science, MEDLINE, Embase, and the Cochrane Library were searched up to November 2018 for relevant randomized controlled trials (RCTs). We conducted a meta-analysis following the guidelines of the Cochrane Reviewer’s Handbook. We used the Cochrane Collaboration’s tool for assessing the risk of bias of each trial. The statistical analysis was performed with Review Manager statistical software (version 5.3).

Results

Eleven RCTs involving 541 patients (541 knees) were included in this meta-analysis. There were 271 patients (271 knees) in the tourniquet group and 270 patients (270 knees) in the no tourniquet group. The results showed that using a tourniquet significantly decreased intraoperative blood loss (P < 0.002), calculated blood loss (P < 0.002), and the time of operation (P < 0.002), but tourniquet use did not significantly decrease postoperative blood loss (P > 0.05), total blood loss (P > 0.05), the rate of transfusion (P > 0.05), and of deep vein thrombosis (DVT) (P > 0.05) in TKA.

Conclusions

Using a tourniquet can significantly decrease intraoperative blood loss, calculated blood loss, and operation time but does not significantly decrease the rate of transfusion or the rate of DVT in TKA. More research is needed to determine if there are fewer complications in TKA without the use of tourniquets.

[Fast track concepts in total knee arthroplasty: use of tranexamic acid and local intra-articular anesthesia technique]

OBJECTIVE

Fast track concepts are used to reduce the risk of perioperative and postoperative complications after total knee arthroplasty.

INDICATIONS

The described concepts are used for patients with indications for the implantation of a total knee prosthesis.

CONTRAINDICATIONS

Contraindications for fast track concepts are aged patients, dementia, American Society of Anesthesiologists (ASA) grade IV and implantation of large revision or tumor prostheses. Contraindications for tranexamic acid are bleeding in the urinary tract, caution in cases of known epilepsy, individual risk assessment in existing thromboses or increased thrombosis risk, fresh myocardial infarction, conditions following fresh pulmonary embolism, percutaneous transluminal coronary angioplasty (PTCA) and stent implantation. Contraindications for ropivacaine are hypersensitivity (allergy) to ropivacaine and other amide type topical anesthetics and hypovolemia.

SURGICAL TECHNIQUE

Preoperative administration of 1 g tranexamic acid and intraoperative local infiltration anesthesia are carried out. After femoral and tibial bone resection and before cementing the femoral and tibial components, approximately 40 ml of ropivacaine (2%) is injected into the posterior capsule. This is followed by injection of the medial and lateral collateral ligaments with approximately 20 ml each and infiltration of Hoffa's fat pad and the extensor apparatus also with approximately 20 ml local anesthetic. After cementing, the subcutaneous tissue is infiltrated with approximately 50 ml ropivacaine solution.

POSTOPERATIVE MANAGEMENT

On the same day as the operation the patient is mobilized with the help of a physiotherapist. The patient should, if possible, walk a few steps on crutches. Systemic analgesic treatment is carried out according to the World Health Organization (WHO) staged scheme II with a weak opioid and first stage non-opioid analgesic (nonsteroidal anti-inflammatory drug, NSAID and/or metamizole). Gabapentin can be used as an adjuvant comedication. Medicinal thrombosis prophylaxis is carried out with a low molecular weight heparin for 2 weeks postoperatively.

RESULTS

In 100 patients who preoperatively received 1 g tranexamic acid and intra-articular infiltration anesthesia, in the evening of the day of the operation the pain was on average 2.1 (±1.8) on the numeric pain rating scale (NPRS). In one patient, there was a sensitive deficit of the lower leg and foot. A motor deficit was not observed. A total of 90 patients were able to raise and straighten leg. On the day of surgery 68 patients were able to walk more than 10 steps and 22 patients could be mobilized to a standing position. The mean length of hospital stay was 6.6 days (5-11 days). No infections, thromboses or pulmonary embolisms occurred.

The efficacy and safety of modified Robert Jones bandage in total knee arthroplasty: A meta-analysis of randomized-controlled trials

BACKGROUND

The efficacy of modified Robert Jones bandage in primary total knee arthroplasty (TKA) is controversial. On the basis of randomized controlled trials (RCTs), this systematic review and meta-analysis was conducted to evaluate the modified Robert Jones bandage in TKA.

METHODS

The electronic databases of EMBASE, PubMed, Web of Science and Cochrane Library were searched from the inception to November 2018 for all relevant English studies. The outcome measurements consisted of total blood loss, hemoglobin decline, transfusion rates, pain score, range of motion, length of hospitalization, knee circumference difference, and adverse effects. Data were analyzed using STATA 14.0 software (The Cochrane Collaboration, Oxford, United Kingdom).Quality assessment was conducted according to the Cochrane Handbook for systematic review of interventions.

RESULTS

A total of 5 randomized controlled trials (RCTs) were included in the systematic review and meta-analysis. The present meta-analysis indicated that there were no significant differences in terms of total blood loss, hemoglobin decline, transfusion rates, pain score, range of motion, length of hospitalization, knee circumference difference, or adverse effects.

CONCLUSIONS

Although published articles have shown improved outcome of blood loss, pain, and knee swelling after application of a modified Robert Jones bandage, our study suggest the use of modified Robert Jones bandage may not be necessary after primary TKA.

Lower extremity regional anesthesia: essentials of our current understanding

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

Do tourniquet and drainage influence fast track in total knee arthroplasty? Our results on 151 cases

Background: Fast track in total knee replacement (TKR) is a widely used protocol. Tranexamic acid proved to be effective in reducing perioperative bleeding without increasing thromboembolic risk. The aim of this study was to assess if tourniquet and suction drainage might affect perioperative blood loss and post-operative functional recovery after TKR. Methods: 151 patients, who underwent to TKR, were assessed and divided into three homogeneous groups: group A (51 patients) in which both tourniquet and suction drainage have been applied (tourniquet has been release before wound closure); group B (50 patients) in which neither tourniquet nor suction drainage have been used; group C (50 patients) in which only tourniquet has been used. Perioperative intravenous tranexamic acid and post-operative low-molecular-weight heparin have been administered. Trend of haemoglobin values, transfusion rate, pain, ability to obtain 90 degrees of flexion and length of stay were analysed. Results: The average intra-operative blood loss was statistically higher in group B in comparison to other two groups. Haemoglobin values were lower in group A in comparison to group C in the third and fifth post-operative days. Patients in group A had higher transfusion rate, higher pain and had more difficulties in reaching a 90 degrees of knee flexion than the other two groups. There was one infection in group A. No differences in length of stay. Conclusion: Suction drain seems to be associated to lower haemoglobin values, higher transfusion rate, higher pain and slower functional recovery. Short-term tourniquet does not influence post-operative bleeding and rehabilitation program. (www.actabiomedica.it)

Multidimensional management of a vascular injury following total knee arthroplasty: A rare case report

Acute vascular injury during total knee arthroplasty (TKA) is an extremely rare complication, but one which can have devastating consequences threatening the limb and/or life of the patient if not diagnosed and managed at the earliest. The clinical presentation can vary from acute haemorrhage or ischemia in the peri operative period; to a delayed presentation of recurrent swelling and pain secondary to a geniculate or popliteal artery pseudoaneurysm. This is the first reported case of an acute inferolateral genicular artery haemorrhage following TKA and the associated medical complications. It was successfully managed with emergency percutaneous endovascular coiling and appropriate medical management. This case highlights that clinical suspicion, prompt diagnosis and urgent intervention with a multidisciplinary approach can help successfully manage a vascular insult.

Blood management in total knee arthroplasty: state-of-the-art review

Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.

Massive haemorrhagic blister formation following total knee arthroplasty

Skin blistering following trauma is not uncommon; however, large haemorrhagic bullous blisters following total knee arthroplasty is relatively rare and not widely documented in the literature.

Outpatient Total Knee Arthroplasty: Are We There Yet? (Part 2)

The method by which surgeons conduct outpatient total knee procedures has yet to be fully elucidated. Literature demonstrates different experiences from various care protocols in place across the nation. This article reviews current recommendations for implementing successful total knee arthroplasty (TKA) and unicompartmental knee arthroplasty outpatient protocols. Specifically, information regarding anesthesia and analgesia modalities, perioperative care, operative technique, and postoperative care within outpatient TKA pathways is discussed.