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

Tourniquet-free minimally invasive total knee arthroplasty is associated with early aseptic loosening

BACKGROUND

While tourniquet-free (T-) total knee arthroplasty (TKA) has gained popularity, tourniquet-use during minimally-invasive (MIS)-TKA has not been adequately studied. Traditional techniques employ knee hyper-flexion, compressing vasculature and reducing impact of bleeding, while MIS-TKA embraces the semi-extended knee position, which does not restrict the effects of bleeding on cementation and visualization. We compared the risk of aseptic loosening between patients undergoing T- MIS-TKA compared to T + MIS-TKA.

METHODS

This single-surgeon cohort study included 329 consecutive MIS-TKA (226 T+,103 T-) patients with minimum 3-year follow-up. Aseptic loosening, radiolucent lines (RLL), health related quality of life scores, and complications were recorded. T-test and chi-square test were used to compare continuous and categorical variables, and logistic regression included BMI, age, ASA, patellar-resurfacing, and tourniquet-use.

RESULTS

There were no differences in baseline demographics. One (0.4 %) aseptic loosening occurred with T+, versus 7 (6.8 %) with T- (p = 0.002). No T + and 3 T- patients (2.9 %, p = 0.01) had revision for aseptic loosening. The incidence of RLLs was 16.8 % in T + and 30.1 % in T- (p = 0.008). Logistic regression revealed T + was significantly associated with decreased aseptic loosening and risk of RLL (odds ratio = 16.4, odds ratio = 2.8).

CONCLUSION

In this consecutive series, T- MIS-TKA was associated with increased rates of revision for aseptic loosening as compared to the T + MIS-TKA, even controlling for BMI, age, ASA level, and patellar resurfacing. Radiolucent lines were increased with T- MIS-TKA compared to T + MIS-TKA. Complications, all-cause revision, ROM, and HRQoL scores were similar between tourniquet-use and tourniquet-free cohorts.

Effects of tourniquet on surgical site wound infection and pain after total knee arthroplasty: A meta-analysis

The application of a tourniquet (TNQ) for haemostasis in total knee arthroplasty (TKA) is controversial and lacking systematic evaluation. This meta-analysis assessed relevant international data to quantitatively evaluate the implications of using TNQ in TKA, further guide clinical diagnosis and treatment, and improve postoperative outcomes. A comprehensive computerised search of PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, VIP, and Wanfang databases was conducted to retrieve randomised controlled trials on the application of TNQ in TKA published from database inception to August 2023. The included data, ultimately comprising 1482 patients in 16 studies, were collated and subjected to meta-analysis using Stata 17.0 software. The results showed that the use of TNQ during TKA led to significantly higher rates of postoperative surgical site wound infection (3.96% vs. 1.79%, odds ratio: 2.15, 95% confidence intervals [CIs]: 1.11-4.16, p = 0.023) and wound pain scores on the first (standardised mean difference [SMD]: 0.65, 95% CI: 0.35-0.94, p < 0.001), second (SMD: 0.66, 95% CI: 0.01-1.31, p = 0.045), and third (SMD: 0.68, 95% CI: 0.31-1.05, pP < 0.001) day after the procedure. In conclusion, the application of TNQ in TKA increases the risk of postoperative surgical site wound infection and worsens short-term postoperative wound pain; therefore, TNQ should be used sparingly during TKA, or its use should be decided in conjunction with the relevant clinical indications and the surgeon's experience.

Consequences of using poly-ether-ether-ketone versus traditional implant on tibial cement penetration and short-term clinical outcomes during total knee arthroplasty: a randomized controlled trial

BACKGROUND

The use of poly-ether-ether-ketone (PEEK) prosthesis during total knee arthroplasty (TKA) is a relatively new concept. Several studies have suggested that the thickness of cement penetration during TKA may affect the stability of the implants. The present study aimed to compare the cement penetration and clinical performance between PEEK and traditional cobalt chromium molybdenum (CoCrMo) prosthesis during TKA.

METHODS

This study was a randomized controlled trial with level I of evidence. A total of 48 patients were randomly assigned to either the PEEK group (n = 24) or the CoCrMo group (n = 24). Mean bone cement penetration under the tibial baseplate was assessed radiographically in four zones in the anteroposterior view and two zones in the lateral view, in accordance with the Knee Society Scoring System. Furthermore, parameters such as the Knee Society Score (KSS), visual analogue scale (VAS) scores, complications and survivorship at 1 year postoperatively were also compared.

RESULTS

According to the results of this study, the mean bone cement penetration exhibited no significant difference between PEEK and CoCrMo groups (2.49 ± 0.61 mm vs. 2.53 ± 0.68 mm, p = 0.85). Additionally, there were no remarkable differences in the KSS clinical score, functional score, and VAS score between the two groups. Moreover, complications and survivorship were also statistically compared between the groups and presented no significant differences.

CONCLUSIONS

Based on the current findings, it can be concluded that PEEK implant present similar bone cement penetration, short-term clinical outcomes, and survivorship with traditional CoCrMo implant in TKA without added complications. Trial registration Chinese Clinical Trial Registry (ChiCTR2100047563).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Are There More Radiolucent Lines in Patients Who Underwent Total Knee Arthroplasty With or Without a Tourniquet During Cementation at 5 to 8 Years After Surgery?

BACKGROUND

This study investigated the presence and progression of radiolucent lines (RLLs) after cemented total knee arthroplasty (TKA) with or without tourniquet use.

METHODS

There were 369 consecutive primary cemented TKAs with 5 to 8 years of follow-up. A tourniquet was used during component cementation in patients who underwent surgery from January 3, 2006, to March 31, 2010. No tourniquet was used from August 14, 2009, to October 14, 2014. There were 192 patients in the tourniquet group (TQ) and 177 patients in the no tourniquet group (NQ). Patient demographics, reoperations, and complications were recorded. RLLs were identified on anteroposterior, lateral, and skyline x-rays at 1, 2, and 5 to 8 years postoperatively using the modern knee society radiographic evaluation system. Demographics, reoperations, complications, and RLLs were compared. Age, sex, and body mass index were similar between groups. Mean tourniquet time in TQ was 11 minutes (range, 8 to 25).

RESULTS

The presence of RLLs differed between groups, with 65% of TQ knees having RLLs under any part of the prostheses versus 46% of NQ knees (P < .001). The progression of RLL >2 mm occurred in 26.0% of knees in TQ and 16.7% of knees in NQ (P = .028). There were 13 TKAs that underwent subsequent revision surgery. There was no statistically or clinically significant difference in revision rate between groups (7 revisions in TQ, 6 in NQ, P = .66).

CONCLUSION

Less RLLs were identified in NQ versus TQ. There were no statistically or clinically significant differences in revision rates between the NQ and TQ groups at 5 to 8 years.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Defining tourniquetless total knee arthroplasty: A systematic review

Introduction

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

Methods

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

Results

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

Conclusion

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

Are there avoidable causes of early revision total knee arthroplasty?

Introduction

Surgeons can improve their practice by understanding potentially avoidable reasons for early revision total knee arthroplasty (rTKA). The purpose of this study is to describe potentially avoidable indications for rTKA within 5 years of the index procedure.

Methods

This retrospective observational analysis utilized the rTKA database at a large, academic orthopedic specialty hospital to identify 167 consecutive rTKA from 2014 to 2019 performed within 5 years after primary TKA (pTKA). Two fellowship-trained arthroplasty surgeons reviewed the cases to classify them as potentially avoidable or unavoidable. Unavoidable indications for rTKA included infection/wound complication, arthrofibrosis, instability due to underlying collagen disease or significant weight loss, and any traumatic event leading to pTKA failure. Potentially avoidable indications included atraumatic instability, intraoperative fracture, metal allergy, and atraumatic patellar instability or maltracking. Aseptic loosening was considered avoidable if it occurred in the presence of component malpositioning or poor cementation technique.

Results

There were 112 (67.1%) unavoidable cases and 55 avoidable cases (32.9%). Of the unavoidable cases, there were 68 rTKA for infection or wound complications (60.7%), 23 for arthrofibrosis (20.5%), 6 for instability (5.4%), 6 for postoperative fracture (5.4%), 6 for aseptic loosening (5.4%), and 3 for extensor mechanism pathology following trauma (2.6%). Of the potentially avoidable rTKA, 24 were for aseptic loosening (43.7%), 23 for atraumatic instability (41.8%), 6 for atraumatic extensor mechanism pathology (10.9%), 1 for nickel allergy (1.8%), and 1 for intraoperative fracture (1.8%).

Conclusion

These findings indicate that over 30% of early rTKA are potentially avoidable. Interventions should focus on addressing potentially avoidable causes such as short-term aseptic loosening and instability to reduce the need for costly and resource-intensive rTKA.

Level of evidence III, retrospective observational analysis

The effects of tourniquet on cement penetration in total knee arthroplasty

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Are cementation quality and clinical outcomes affected by the use of tourniquet in primary total knee arthroplasty?

INTRODUCTION

Total knee arthroplasty is used to treat end-stage knee osteoarthritis with great results. Tourniquet use has become popular over the years because of its various benefits, but the literature regarding functional outcomes, pain and rehabilitation and comparison between tourniquet use and improvement cement penetration and overall improve fixation is limited. The authors proposed a hypothesis that cementation quality, and clinical outcomes can be influenced by tourniquet technique.

METHODS

Fifty patients were allocated randomly in two groups: (1) tourniquet was inflated throughout all the procedure and (2) only during skin incision and cementation. Radiolucent lines were analyzed by two and independent examiners, using the The Knee Society Roentgenographic Evaluation and Scoring System. The functional scores used were the Oxford knee score and improvement in visual pain scale (VAS).

RESULTS

After a mean follow-up period of 2.4 ± 0.2 years, no difference was observed regarding partial use of tourniquet in the cementation quality (p value > 0.05). There was no difference between groups regarding gender, age, knee side, Visual VAS, Oxford Score, total range-of-motion (ROM), knee extension and knee flexion (p value > 0.05).

CONCLUSIONS

No difference was attained regarding functional outcomes and cementation quality regarding two different tourniquet protocols.

Association of Use of Tourniquets During Total Knee Arthroplasty in the Elderly Patients With Post-operative Pain and Return to Function

Objective

During total knee arthroplasty (TKA), tourniquet may negatively impact post-operative functional recovery. This study aimed at investigating the effects of tourniquet on pain and return to function.

Methods

Pubmed, Embase, and Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15th, 2020. Search terms included; total knee arthroplasty, tourniquet, and randomized controlled trial. RCTs evaluating the efficacies of tourniquet during and after operation were selected. Two reviewers independently extracted the data. Effect estimates with 95% CIs were pooled using the random-effects model. Dichotomous data were calculated as relative risks (RR) with 95% confidence intervals (CI). Mean differences (MD) with 95% CI were used to measure the impact of consecutive results. Primary outcomes were the range of motion (ROM) and visual analog scale (VAS) pain scores.

Results

Thirty-three RCTs involving a total of 2,393 patients were included in this study. The mean age is 65.58 years old. Compared to no tourniquet group, the use of a tourniquet resulted in suppressed ROM on the 3rd post-operative day [MD, −4.67; (95% CI, −8.00 to −1.35)] and the 1st post-operative month [MD, −3.18; (95% CI, −5.92 to −0.44)]. Pain increased significantly when using tourniquets on the third day after surgery [MD, 0.39; (95% CI, −0.19 to 0.59)]. Moreover, tourniquets can reduce intra-operative blood loss [MD, −127.67; (95% CI, −186.83 to −68.50)], shorter operation time [MD, −3.73; (95% CI, −5.98 to −1.48)], lower transfusion rate [RR, 0.85; (95% CI, 0.73–1.00)], higher superficial wound infection rates RR, 2.43; [(5% CI, 1.04–5.67)] and higher all complication rates [RR, 1.98; (95% CI, 1.22–3.22)].

Conclusion

Moderate certainty evidence shows that the use of a tourniquet was associated with an increased risk of higher superficial wound infection rates and all complication rates. Therefore, the findings did not support the routine use of a tourniquet during TKA.

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.

The technique of cement application has no influence on cement intrusion in total knee arthroplasty: randomized study comparing three different techniques

PURPOSE

The aim of the study was to compare the distance of intrusion of the cement into the bone in different areas both in the femur and the tibia in vivo, measured in the radiograph after implanting a total knee arthroplasty (TKA) with three different cement techniques.

METHODS

A prospective randomized study of 90 consecutive patients operated on at our institution with a cemented U2 Knee System TKA and medium viscosity Simplex P^® bone cement. After pulse lavage, the cement was applied on the bone surfaces (group 1), on the implant surfaces (group 2) or both on the bone and the implant surfaces (group 3). The cement intrusion was measured in the postoperative radiographs in eight different regions in the tibial component and in six regions in the femoral component. The cement employed was calculated by weighting the cement after mixing and weighting the discarded cement.

RESULTS

The average intrusion of the cement was similar in all three groups of cementing techniques in the femoral components (1.6 mm; p = 0.386), and in the tibial components (2.6 mm; p = 0.144). The intrusion of the cement in the tibia was greater in women than in men (p = 0.04). We used 21.1 (SD 5.8) g of cement in average. The amount of cement employed was greater when the cement was applied on both (implant and bone) surfaces (group 3: 24.03 g in average) than when it was applied only on the bone (group 1: 20.13 g; p = 0.01) or only on the implants (group 2: 19.20 g; p = 0.001). The amount of cement employed was greater in men than in women (p = 0.002) and it was also greater when a PS femoral component was used (p = 0.03). The amount of cement employed was directly correlated with the height of the patients (p = 0.01) and with the bigger size of the components (p < 0.001).

CONCLUSION

All three cement application techniques have similar intrusion distance of the cement into the bone, and the intrusion depth of the cement into the trabecular tibial bone is greater than the minimum suggested for fixation.

Not using a tourniquet is superior to tourniquet use for high tibial osteotomy: a prospective, randomised controlled trial

PURPOSE

Tourniquets are routinely used in high tibial osteotomy (HTO). However, research on the necessity of tourniquets during HTO is lacking. This study was designed to investigate the necessity of tourniquets in HTO.

METHODS

This was a prospective study that included patients who underwent HTO at the same hospital. The patients were randomised into Group A (non-tourniquet, n = 45) and Group B (tourniquet, n = 45). Same surgical techniques and haemostatic methods were used in the two groups.

RESULTS

All patients were followed up for more than three months. There was no difference in operation time, and no intra-operative vascular or nerve damage occurred in either group. The hospital stay was shorter in group A than in group B (p < 0.05). There was no difference in post-operative blood loss, haemoglobin or haematocrit (p > 0.05). The post-operative visual analogue scale (VAS) pain scores and calf swelling were lower in group A (p < 0.05), and the early knee range of motion was higher in group A (p < 0.05). The use of morphine and the incidence of thigh complications were also lower in group A (p < 0.05). There was no difference in the VAS and knee function between the two groups at three months post-operatively (p > 0.05).

CONCLUSION

Tourniquet use during HTO does not reduce post-operative blood loss, operation time or intra-operative complications, but not using a tourniquet shortens the hospital stay and reduces the post-operative usage of morphine and tourniquet-related complications, which promotes early recovery of knee function.

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

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

A survey of the use of tourniquet among orthopaedic surgeons in Nigeria

Background

The modern arterial tourniquet is an automatic tourniquet system which contains many features that help to minimise complications and improve safety. However, the non-pneumatic tourniquet is still in use, a practice that may be commoner in resource-constrained settings. This study was conducted to investigate the types of tourniquet available and used by orthopaedic surgeons in Nigeria as well as the practical aspects and complications of their use of the tourniquet.

Materials and Methods

At an Annual General Meeting/Scientific Conference of Nigerian Orthopaedic Association, a survey was conducted among orthopaedic surgeons using a pre-tested self-administered questionnaire which contained questions on types of tourniquet, practical aspects of the use of tourniquet and complications.

Results

The non-pneumatic tourniquet was usually used by 60.2% of the respondents and 58.1% of those who had both pneumatic and non-pneumatic tourniquets used the latter more commonly. In most cases, the tourniquet was applied by surgeons or surgical residents on the arm or thigh. Surgeons who had ever used the tourniquet in diabetic patients were 71.6% while 29.5% had used it in patients with sickle cell disease. Tourniquet duration was usually 1½ h and 2 h in the upper and lower limbs, respectively. The two most common complications were tourniquet palsy and tourniquet pain.

Conclusions

The non-pneumatic tourniquet was more commonly used than the pneumatic tourniquet. Application of the tourniquet on sites other than the thigh and the upper arm were uncommon. The most common complication was neurologic injury.

Effect of tourniquet application on cement penetration in primary total knee arthroplasty: a meta-analysis

Background

Tourniquet application is expected to improve surgery exposure and cementation process in total knee arthroplasty (TKA) but its effectiveness remains controversial and needs to be further explored. The aim of this meta-analysis was to assess the effect of tourniquet in primary TKA. The hypothesis is that the tourniquet application affects the cement penetration in TKA.

Methods

A search was conducted in PubMed, Embase, and the Cochrane Library for the potentially eligible articles. Two independent researchers reviewed the articles retrieved against the pre-designed inclusion and exclusion criteria. In primary TKA, cement penetration was assessed, and the data between the tourniquet-assisted and non-tourniquet-assisted TKAs were compared. Statistical significance was set at P < 0.05.

Results

A total of 4 randomized controlled trials and 3 non-randomized controlled trials (involving 675 patients) were included. There was no significant difference between the tourniquet-assisted and non-tourniquet-assisted TKAs in terms of cement penetration (P > 0.05). There were no significant differences in the total surgical time, blood loss, blood transfusion, the Knee Society Score, and the visual analogue scale (VAS) between the two kinds of procedures (P > 0.05).

Conclusions

Tourniquet application may not affect cement penetration in primary TKA and may not help reduce blood loss, ease knee pain or improve the knee function. A surgeon may choose to use a tourniquet or not according to his or her own preference.

Level of Evidence

Level Ib, meta-analysis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cementing technique for total knee arthroplasty in cadavers using a pastry bone cement

Background

In cemented primary total knee arthroplasty (TKA), aseptic loosening remains a major cause for failure. Cementing techniques and characteristics of a chosen cement play a key role for good fixation and implant survival. A pastry bone cement was developed to facilitate the cement preparation and to rule out most of preparation-associated application errors. The pastry bone cement was compared to a conventional polymethyl methacrylate cement in a TKA setting.

Methods

Standardized implantations of total knee endoprostheses were performed in bilateral knee cadavers to investigate handling properties, variables of cement application, working time, and temperature development. Mechanical aspects and cementation quality were assessed by pull-out trials and microscopic interface analysis.

Results

Both cements expressed similar characteristics during preparation and application, only the curing time of the pastry cement was about 3 min longer and the temperature peak was lower. Fractures of the conventional cement specimens differed from the pastry cement specimens in the tibial part, while no differences were found in the femoral part. Penetration depth of the pastry cement was similar (tibia) or deeper (femur) compared to the conventional cement.

Conclusions

The pastry cement facilitates the feasibility of cemented TKA. The pre-clinical tests indicate that the pastry bone cement fulfills the requirements for bone cement in the field of knee arthroplasty. A clinical trial is needed to further investigate the approach and ensure patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02436-z.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparing the effect of tourniquet and tranexamic acid on the tibial cement mantle thickness in total knee arthroplasty

BACKGROUND

This study aims to determine the efficacy of both tranexamic acid (TXA) and tourniquet on the tibial cement mantle thickness in total knee arthroplasty (TKA).

METHODS

We retrospectively reviewed the recorded data of patients with primary end-stage knee osteoarthritis who underwent TKA procedure during 2014-2016 at a single institution to evaluate the tibial cement mantle. Patients were categorized in two groups based on the use of tourniquet (groups 1 and 2). In addition, these groups were categorized into two different subgroups based on the use of TXA in groups 1 and 2 (group 1-A, B and group 2-A, B). Four zones at the tibial baseplate on the anteroposterior view and two zones on the lateral view were measured at the 4-6-week postoperative visit.

RESULTS

A total of 28 patients (30 knees) were operated using tourniquet and TXA (group 1-A), 29 (30 knees) using tourniquet without TXA (group 1-B), 24 (28 knees) using TXA without tourniquet (group 2-A), and 38 (42 knees) without using TXA and tourniquet (group 2-B). Although a significant difference was found in the cumulative cement mantle penetration on postoperative X-rays between groups 1 and 2, no significant differences were found between groups A and B in both groups.

CONCLUSIONS

This study reports that tourniquet use in TKA increased cement mantle penetration of the tibial component in primary TKA. The main strength of this study was that the TXA use alone exhibited no significant effect on the cement thickness.

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.

Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery

Aims

Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Methods

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.

Results

We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87).

Conclusion

TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery.

Cite this article: Bone Joint J 2021;103-B(5):830–839.

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.

Does tourniquet use affect the periprosthetic bone cement penetration in total knee arthroplasty? A meta-analysis

BACKGROUND

A tourniquet is a device commonly used to control massive hemorrhage during knee replacement surgery. However, the question remains whether the use of tourniquets affects the permeability of the bone cement around the knee prosthesis. Moreover, the long-term effects and stability of the knee prosthesis are still debatable. The aim of this study was to examine whether the use of a tourniquet increases the thickness of the cement mantle and affects the postoperative blood loss and pain during primary total knee arthroplasty (TKA) using meta-analysis.

METHODS

We searched the Cochrane Central Library, MEDLINE, Embase, PubMed, CNKI, and Wang Fang databases for randomized controlled trials (RCTs) on primary TKA, from inception to November 2019. All RCTs in primary TKA with and without a tourniquet were included. The meta-analysis was conducted using RevMan 5.2 software.

RESULTS

A total of eight RCTs (677 knees) were analyzed. We found no significant difference in the age and sex of the patients. The results showed that the application of tourniquet affects the thickness of the bone cement around the tibial prosthesis (WMD = 0.16, 95%CI = 0.11 to 0.21, p < 0.00001). However, in our study, there was no significant difference in postoperative blood loss between the two groups was observed (WMD = 12.07, 95%CI = - 78.63 to 102.77, p = 0.79). The use of an intraoperative tourniquet can increase the intensity of postoperative pain (WMD = 1.34, 95%, CI = 0.32 to 2.36, p = 0.01).

CONCLUSIONS

Tourniquet application increases the thickness of the bone cement around the prosthesis and may thus increase the stability and durability of the prosthesis after TKA. The application of an intraoperative tourniquet can increase the intensity of postoperative pain.

Tourniquet use for knee replacement surgery

BACKGROUND

Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. A tourniquet may be associated with increased risk of pain and complications.

OBJECTIVES

To determine the benefits and harms of tourniquet use in knee replacement surgery.

SEARCH METHODS

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to 26 March 2020. We searched clinicaltrials.gov, the World Health Organization trials portal, and several international registries and joint registries up to March 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing knee replacement with use of a tourniquet versus without use of a tourniquet and non-randomised studies with more than 1000 participants. Major outcomes included pain, function, global assessment of success, health-related quality of life, serious adverse events (including venous thromboembolism, infection, re-operation, and mortality), cognitive function, and survival of the implant. Minor outcomes included blood loss, economic outcomes, implant stability, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full texts, extracted data, performed risk of bias assessments, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 41 RCTs with 2819 participants. Trials included from 20 to 199 participants. Mean age ranged between 58 and 84 years. More than half of the RCTs had unclear risk of selection bias and unclear risk of performance and detection bias due to absence of blinding of participants and surgeons. Major outcomes Pain: at postoperative day 1, pain (on a scale from zero to 10, with higher scores indicating worse pain) was ranked at 4.56 points after surgery without a tourniquet and at 1.25 points (MD) higher (95% CI 0.32 higher to 2.19 higher) with a tourniquet (8 studies; 577 participants), for an absolute difference of 12.5% higher pain scores (95% CI 3.2% higher to 21.9% higher) and a relative difference of 19% higher pain scores (95% CI 3.4% higher to 49% higher) with a tourniquet. Evidence for these findings was of moderate certainty, downgraded due to risk of bias. Knee replacement with a tourniquet probably led to higher postoperative pain scores at day 1, although this difference may or may not be noticeable to patients (based on a minimal clinically important difference (MCID) of 1.0). Function: at 12 months, tourniquet use probably makes little or no difference to function, based on an MCID of 5.3 for Knee Society Score (KSS) and 5.0 for Oxford Knee Score (OKS). Mean function (on a scale from 0 to 100, with higher scores indicating better outcomes) was 90.03 points after surgery without a tourniquet and was 0.29 points worse (95% CI 1.06 worse to 0.48 better) on a 0 to 100 scale, absolute difference was 0.29% worse (1.06% worse to 0.48% better), with a tourniquet (5 studies; 611 participants). This evidence was downgraded to moderate certainty due to risk of bias. Global assessment of success: low-certainty evidence (downgraded due to bias and imprecision) indicates that tourniquet use may have little or no effect on success. At six months, 47 of 50 (or 940 per 1000) reported overall successful treatment after surgery without a tourniquet and 47 of 50 (or 940 per 1000) with a tourniquet (risk ratio (RR) 1.0, 95% CI 0.91 to 1.10) based on one study with 100 participants. Health-related quality of life: at six months, tourniquet may have little or no effect on quality of life. The 12-Item Short Form Survey (SF-12) score (mental component from zero to 100 (100 is best)) was 54.64 after surgery without a tourniquet and 1.53 (MD) better (95% CI 0.85 worse to 3.91 better) with a tourniquet (1 study; 199 participants); absolute difference was 1.53% better (0.85% worse to 3.91% better). Evidence was of low certainty, downgraded due to risk of bias and small number of participants. Serious adverse events: the risk of serious adverse events was probably higher with tourniquet; 26 of 898 (29 per 1000) reported events following surgery without a tourniquet compared to 53 of 901 (59 per 1000) with a tourniquet (RR 1.73, 95% CI 1.10 to 2.73) in 21 studies (1799 participants). Twenty-nine more per 1000 patients (95% CI 3 to 50 more per 1000 patients) had a serious adverse event with a tourniquet. Forty-eight (95% CI 20 to 345) participants would need to have surgery without a tourniquet to avoid one serious adverse event. This evidence was downgraded to moderate certainty due to risk of bias. Cognitive function: one study reported cognitive function as an outcome; however the data were incompletely reported and could not be extracted for analysis. Survival of implant: it is uncertain if tourniquet has an effect on implant survival due to very low certainty evidence (downgraded for bias, and twice due to very low event rates); 2 of 107 (19 per 1000) required revision surgery in the surgery with a tourniquet group compared to 1 of 107 (9 per 1000) without a tourniquet group at up to two years' follow-up (RR 1.44, 95% CI 0.23 to 8.92). This equates to a 0.4% (0.7% lower to 7% more) increased absolute risk in surgery with a tourniquet.

AUTHORS' CONCLUSIONS

Moderate certainty evidence shows that knee replacement surgery with a tourniquet is probably associated with an increased risk of serious adverse events. Surgery with a tourniquet is also probably associated with higher postoperative pain, although this difference may or may not be noticeable to patients. Surgery with a tourniquet does not appear to confer any clinically meaningful benefit on function, treatment success or quality of life. Further research is required to explore the effects of tourniquet use on cognitive function and implant survival, to identify any additional harms or benefits. If a tourniquet continues to be used in knee replacement surgery, patients should be informed about the potential increased risk of serious adverse events and postoperative pain.

A matched cohort study between cementless TKA and cemented TKA shows a reduction in tourniquet time and manipulation rate

Introduction

Cementless total knee arthroplasty (TKA) is now becoming more acceptable with the advent of newer ongrowth constructs and better initial fixation. It has been proposed that cementless TKA may save OR time and result in a lower incidence of manipulation. This study was designed to assess the difference between cemented and cementless TKA.

Methods

Our hospital statistician performed a matched cohort analysis between 127 cementless TKAs and 127 cemented TKRs performed by a single surgeon. Patients were matched on age and BMI. Mean tourniquet time between the cemented and cementless TKAs was assessed as well as the rate of manipulation between these groups. Of note, a tourniquet was routinely used in both the cementless and cemented cohorts to reduce confounding bias.

Results

A total of 127 cementless TKAs with a mean age of 60.8 years and mean BMI 32.2 were compared to 127 cemented TKAs with a mean age of 61.5 years and mean BMI of 32.2 at an average follow-up of 2.0 years. There was a statistically significant reduction in tourniquet time in the cementless TKA cohort at 45.7 min compared to the cemented TKA cohort at 54.8 min (p = 0.001). Estimated blood loss was similar in both the cementless (179.5 ml) and cemented (196 ml) cohorts (p = 0.3) and postoperative outcomes, including UCLA score.In addition, the cementless TKA cohort had a manipulation rate of 0% compared to 3.1% for the cemented TKA group (p = 0.044).

Discussion and conclusion

While cementless and cemented TKA have shown similar PROMs and survivorship, we demonstrated a significant reduction in tourniquet time with cementless TKRs, with similar estimated blood loss, and a lower incidence of manipulation with cementless TKRs in this matched cohort study. The increased cost of a cementless implant may be negated if one considers the cost savings of not using cement, the cost savings of not performing manipulations, and the shorter operative time.

Use of Tourniquet During Knee Arthroplasty in Patients With Radiographic Arterial Calcifications

BACKGROUND

Use of tourniquet during total knee arthroplasty (TKA) in patients with radiographic arterial calcifications is controversial. Intimal arterial calcifications are feared to be associated with ischemic complications such as delayed wound healing and arterial thrombosis, whereas medial calcifications stiffen the arterial wall, possibly leading to tourniquet failure and increased blood loss.

METHODS

We conducted a prospective cohort study to determine the incidence of tourniquet failure (inflated up to 300 mm Hg), blood transfusions, wound healing, and ischemic complications in thighs with and without arterial calcifications on preoperative radiographs, in 2548 consecutive primary TKAs conducted in our unit over a 5-year period. Eighty-six thighs showed vascular calcifications: 58 medial and 28 intimal.

RESULTS

Thighs with vascular calcifications had higher risk of tourniquet failure as compared to those without calcifications (P < .001), but with no significant increase in incidence of blood transfusions. All cases of tourniquet failure in the calcification group occurred in thighs with medial calcifications, whereas all cases of tourniquet failure in the control group occurred in obese patients. There was no difference in wound healing and ischemic complications in limbs with and without arterial calcifications.

CONCLUSION

The presence of arterial calcifications on preoperative radiographs increases the risk of tourniquet failure at 300 mm Hg in patients undergoing TKA, with no significant increase in rate of blood transfusions, wound healing or ischemic complications.

The Effect of Tranexamic Acid and Tourniquet Use on Tibial Cement Penetration in Primary Total Knee Arthroplasties

Background

In this study, our aim was to compare the effects of tourniquet and tranexamic acid (TXA) use on tibial cement penetration in primary total knee arthroplasty (TKA) using radiograph images. In addition, we also aimed at investigating the effects of age, gender, body mass index (BMI), and bone mineral density on cement penetration.

Methods

One hundred seventy patients who underwent TKA for primary osteoarthritis were retrospectively evaluated. TXA was administered to patients in group 1 (n = 96), and tourniquet application was used in patients in group 2 (n = 74). Tibial cement penetration was evaluated radiologically on a total of 4 zones: 2 anteroposterior and 2 lateral zones. In addition, age, gender, BMI, and bone mineral density were recorded in each group.

Results

The mean cement penetration in the total study population was 2.34 ± 0.24 mm, with a mean of 2.33 ± 0.25 mm in the TXA group and a mean of 2.35 ± 0.24 mm in the tourniquet group (P = .453). A negative correlation was detected between BMI and anteroposterior 1 values in the total and TXA groups (P = .022 and P = .029). In the evaluation of the differences between genders, significantly higher penetration values were observed only in the females in the tourniquet group (P = .024).

Conclusions

The use of TXA instead of a tourniquet does not reduce the depth of cement penetration in TKA. The clinical implications of individual-induced penetration differences may be significant for future implant survival.

More pain and slower functional recovery when a tourniquet is used during total knee arthroplasty

PURPOSE

Although a tourniquet can effectively control intraoperative blood loss and offer clear surgical field in total knee arthroplasty (TKA), its optimal usage has been controversial. The aim of this research was to perform a systematic review and meta-analysis to compare and explore the best application of a tourniquet in TKA.

METHODS

MEDLINE, PubMed, EMBASE, the Cochrane Library, Wanfang database, and Web of Science were searched for randomized controlled trials (RCTs) comparing the four different strategies of tourniquet application in TKA. In Group I, a tourniquet was not used and was called the non-tourniquet (NT) group. In Group II, a tourniquet was only used during the cementation of implants and was called the specific duration tourniquet (SDT) group. In Group III, the tourniquet was only released before wound closure to control the bleeding sources and was called the majority duration tourniquet (MDT) group. In Group IV, a tourniquet was used throughout the procedure, from skin incision to wound closure and was called the whole duration tourniquet (WDT) group.

RESULTS

Forty-six RCTs were included in this systematic review and meta-analysis. In a comparison between the NT and WDT groups (25 RCTs), intraoperative blood loss (IBL) (P = 0.0001) and range of motion (ROM) (P = 0.0001) were significantly increased in the NT group, while the visual analog score (VAS) (P = 0.0001), rate of deep vein thrombosis (DVT) (P = 0.01), and all complications (AC) (P = 0.0001) were significantly decreased in the NT group. In a comparison between the SDT and WDT groups (10 RCTs), IBL (P = 0.0001), TBL (P = 0.009), and ROM (P = 0.0001) were significantly increased in the SDT group, while thigh pain (P = 0.04) and the rate of DVT (P = 0.03) were significantly decreased in the SDT group. There were no significant differences between the MDT and WDT groups (12 RCTs) except for the rate of all complications (P = 0.01).

CONCLUSION

Despite the decrease in IBL with a tourniquet, no difference was found in TBL. In conclusion, not using a tourniquet or only using it during the cementation of implants was preferable based on the faster functional recovery, lower rate of DVTs and complications compared with using a tourniquet throughout the TKA procedure.

LEVEL OF EVIDENCE

I.

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.

Controversial Topics in Total Knee Arthroplasty: A Five-Year Update (Part 2)

This review article examines updates to the literature during the past 5 years on numerous topics which were felt to have ongoing controversy. These topics include venous thromboprophylaxis, tranexamic acid usage, tourniquet usage, and wound closure techniques.

Hemostatic techniques to reduce blood transfusion after primary TKA: a meta-analysis and systematic review

PURPOSE

To investigate the efficacy of non-tranexamic acid (TXA) on reducing blood loss and requirements of allogeneic blood transfusion (ABT) in total knee arthroplasty (TKA).

METHODS

The PubMed, EMBASE, and the Cochrane Library databases were researched since incipiency to June 2018. Only randomized controlled trials (RCTs) involved with non-TXA hemostatic techniques in TKA met the inclusion criteria.

RESULTS

A total of 36 RCTs, including 1511 patients, were recruited for analysis. The results of subgroup analysis revealed that hemostatic techniques, which could substantially decrease the rate of ABT, were cell salvage with the transfusion trigger of 9 mg/dl, fibrin sealant with a dosage of 10 ml, and postoperative flexion position.

CONCLUSION

The available evidence in this meta-analysis suggests that postoperative flexion position, fibrin sealant, and cell salvage can substantially decrease the rate of ABT in TKA. Further studies, including more hemostatic methods and high-quality research, are expected.

[Effect of pneumatic tourniquet on perioperative blood loss in total knee arthroplasty]

Objective

To evaluate the effect of pneumatic tourniquet on perioperative period of total knee arthroplasty (TKA).

Methods

The perioperative period data of 116 patients over 60 years old with severe knee osteoarthritis treated with TKA between January 2018 and January 2019 were retrospectively analyzed. According to whether pneumatic tourniquet was used during operation, the patients were divided into trial group (49 cases, pneumatic tourniquet was not used during operation) and control group (67 cases, pneumatic tourniquet was used during operation). There was no significant difference in gender, age, body mass index, lesion side, disease duration, and preoperative hemoglobin between the two groups ( P>0.05). The operation time, actual total blood loss, overt blood loss, hidden blood loss, and percentage of hidden blood loss, knee swelling at 3 days after operation, and range of motion of knee at 2 weeks after operation were recorded and compared between the two groups.

Results

The operation time of the trial group was significantly longer than that of the control group ( t=14.013, P=0.000). The actual total blood loss, hidden blood loss, and percentage of hidden blood loss in the trial group were significantly lower than those in the control group ( P<0.05); there was no significant difference in the overt blood loss between the two groups ( t=-1.293, P=0.200). The knee swelling degree in the trial group was significantly slighter than that in the control group at 3 days after operation, and the range of motion of knee in the trial group was significantly better than that in the control group at 2 weeks after operation ( P<0.05).

Conclusion

Pneumatic tourniquet can reduce the operation time of TKA significantly. However, it may increase the hidden blood loss and knee swelling, and negatively impact the recovery of knee function in the early postoperative stage of TKA.

Does Tourniquet Use in TKA Increase Postoperative Pain? A Systematic Review and Meta-analysis

BACKGROUND

Although tourniquets are commonly used during TKA, that practice has long been surrounded by controversy. Quantifying the case for or against tourniquet use in TKA, in terms of patient-reported outcomes such as postoperative pain, is a priority.

QUESTIONS/PURPOSES

The purpose of this study was to meta-analyze the available randomized trials on tourniquet use during TKA to determine whether use of a tourniquet during TKA (either for the entire procedure or some portion of it) is associated with (1) increased postoperative pain; (2) decreased ROM; and (3) longer lengths of hospital stay (LOS) compared with TKAs performed without a tourniquet.

METHODS

We completed a systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines to assess the impact of tourniquet use on patients after TKA. We searched the following databases from inception to February 1, 2015, for randomized controlled trials meeting prespecified inclusion criteria: PubMed, Embase, and Cochrane Central Register of Controlled Trials. Postoperative pain was the primary outcome. Secondary outcomes were postoperative ROM and LOS. The initial search yielded 218 studies, of which 14 met the inclusion criteria. For our primary analysis on pain and ROM, a total of eight studies (221 patients in the tourniquet group, 219 patients in the no-tourniquet group) were meta-analyzed. We also performed a subgroup meta-analysis on two studies that used the tourniquet only for a portion of the procedure (from osteotomy until the leg was wrapped with bandages) and defined this as half-course tourniquet use (n = 62 in this analysis). The Jadad scale was used to ascertain methodological quality, which ranged from 3 to 5 with a maximum possible score of 5. Statistical heterogeneity was tested with I and chi-square tests. A fixed-effects (inverse variance) model was used when the effects were homogenous, which was only the case for postoperative pain; the other endpoints had moderate or high levels of heterogeneity. Publication bias was assessed using a funnel plot, and postoperative pain showed no evidence of publication bias, but the endpoint of LOS may have suffered from publication bias or poor methodological quality. We defined the minimum clinically important difference (MCID) in pain as 20 mm on the 100-mm visual analog scale (VAS).

RESULTS

We found no clinically important difference in mean pain scores between patients treated with a tourniquet and those treated without one (5.23 ± 1.94 cm versus 3.78 ± 1.61 cm; standardized [STD] mean difference 0.88 cm; 95% confidence interval [CI], 0.54-1.23; p < 0.001). None of the studies met the MCID of 20 mm in VAS pain scores. There was also no clinically important difference in ROM based on degrees of flexion between the two groups (49 ± 21 versus 56 ± 22; STD mean difference 0.8; 95% CI, 0.4-1.1; p < 0.001). Similarly, we found no difference in mean LOS between groups (5.8 ± 4.4 versus 5.9 ± 4.6; STD mean difference -0.2; 95% CI, -0.4 to 0.1; p = 0.25). A subgroup meta-analysis also showed no clinically important difference in pain between the full-course and half-course tourniquet groups (5.17 ± 0.98 cm versus 4.09 ± 1.08 cm; STD mean difference 1.31 cm; 95% CI, -0.16 to 2.78; p = 0.08).

CONCLUSIONS

We found no clinically important differences in pain or ROM between patients treated with and without tourniquets during TKA and no differences between the groups in terms of LOS. In the absence of short-term benefits of avoiding tourniquets, long-term harms must be considered; it is possible that use of a tourniquet improves a surgeon's visualization of the operative field and the quality of the cement technique, either of which may improve the long-term survivorship or patient function, but those endpoints could not be assessed here. We recommend that the randomized trials discussed in this meta-analysis follow patients from the original series to determine if there might be any long-term differences in pain or ROM after tourniquet use.

LEVEL OF EVIDENCE

Level I, therapeutic study.