Intramedullary sealing with a bone plug in total knee arthroplasty to reduce blood loss: a meta-analysis of randomized controlled trials

Does the accelerometer-based navigation system reduce blood loss and transfusion in one-stage sequential bilateral total knee arthroplasty? A randomized double-blind controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with significant blood loss and postoperative transfusion. The accelerometer-based navigation (ABN) system guides the bone cutting plane without breaching the intramedullary canal, which may reduce bleeding. This study aimed to investigate blood loss and transfusion compared between the ABN system and the conventional procedure in patients undergoing one-stage sequential bilateral TKA (SBTKA).

METHODS

A total of 66 patients scheduled for SBTKA were randomly allocated to either the ABN or conventional group. Postoperative hematocrit (Hct) level, drainage blood loss, transfusion rate, and amount of packed red cell transfusion were collected. Total red blood cell (RBC) loss was then calculated for the primary outcome.

RESULTS

The mean calculated total RBC loss in the ABN and conventional group was 669.7 and 630.0 mL, respectively (p = 0.572). There was no significant difference between groups for other evaluated outcome parameters, including postoperative Hct level, drainage blood loss, or packed red cell transfusion volume. All patients in the conventional group required postoperative blood transfusion while 96.8% of patients in the ABN group were transfused.

CONCLUSIONS

The total RBC loss and volume of packed red cells transfusion were not significant difference between interventions, which suggest no benefit of the ABN system in reducing blood loss and transfusion in patients undergoing SBTKA.

TRIAL REGISTRATION

The protocol of this study was registered in the Thai Clinical Trials Registry database no. TCTR20201126002 on 26/11/2020.

Accelerometer-Based Handheld Navigation Instrumentation in Total Knee Arthroplasty Decrease Blood Loss Compared to Conventional Instrumentation: A Prospective Comparative Study

Introduction Total Knee Arthroplasty (TKA) can be associated with significant peri- and post-operative blood loss necessitating blood transfusion. The blood loss may be relatively less when the accelerometer-based handheld navigation system (HHNS) is used, as there is neither a need for intramedullary breach nor additional pin insertions. The primary hypothesis was that HHNS instrumentation reduced perioperative blood loss when compared with conventional instrumentation, and to prove this, we compared the perioperative parameters like tourniquet time, hemoglobin loss, and estimated blood loss between patients undergoing total knee arthroplasty using conventional instrumentation with handheld navigation instrumentation. Methods This prospective comparative study involves 40 patients in the HHNS group and 40 patients in the conventional group based on the instrumentation used, respectively. Tourniquet was used in all the cases. Patient characteristics like age, sex, body mass index (BMI), American Society of Anaesthesiologists (ASA) grade, and Charlson Comorbidity Index (CCI) were recorded. The perioperative parameters like tourniquet time, the estimated blood loss, hemoglobin loss, blood transfusions, and the number of units transfused were recorded and compared between the groups. Results There was no significant difference in age, BMI, ASA grade, or CCI between the two groups. The tourniquet time was 83.7 ± 9.6 in the navigation and 73.9 ± 10.3 in the conventional group. The estimated Hb loss was lower at 2.5 ± 1.6 in the HHNS group compared to 3.0 ± 1.8 in the conventional group (p<0.001). Similarly, estimated blood loss was also lower at 830 ± 285ml for the HHNS group compared to 1088 ± 228 in the conventional group. Two patients in the navigation group had a total of four units transfused, whereas three patients in the conventional group had five units of blood transfusion. Conclusions The primary hypothesis that HHNS reduced perioperative blood loss was confirmed by the results of our study. We demonstrated that HHNS instrumentation significantly decreased the estimated blood loss, drain volume, and hemoglobin loss compared to conventional instrumentation with similar operating times. Though blood transfusions were seen in fewer patients, there was no significant reduction in blood transfusions by HHNS instrumentation.

Comparison of three methods for sealing of the intramedullary femoral canal during total knee arthroplasty; a randomized controlled trial

PURPOSE

The purpose of this randomized controlled study was to examine the effect of sealing the intramedullary canal with a bone or cement plug or leaving it empty on postoperative bleeding and pain MATERIALS AND METHODS: A total of 120 patients with knee osteoarthritis who underwent unilateral TKA participated in the trial and were assigned to one of three groups. The femoral canal was sealed with an autogenous bone plug (Group I) or cement plug (Group II), or it was left open (Group III). Estimated blood loss, Hemoglobin decline, bleeding into the drain, and postoperative pain w compared between groups.

RESULTS

Six patients were excluded due to various reasons, and the remaining 114 patients were included in the final analysis. There were no significant variations in baseline clinical characteristics between the three groups (p > 0.05). Hemoglobin reduction between preoperative and 72 h after the surgery (p: 0.034) and estimated blood loss (p: 0.003) were significantly different between groups. The cement plug group showed the least bleeding. Although there was a significant difference between the cement and empty canal groups (p: 0.03 and p: 0.002, respectively), the difference between the cement and bone groups was similar regarding both hemoglobin reduction and estimated blood loss. The blood volume in the suction drain (p: 0.598) and transfusion rate (p: 0.087) were similar between the groups. VAS at the 12 h after the surgery was similarly high in each group (p: 0.676). It declined at 36 h after surgery, but no significant difference was determined between groups (p: 0.815).

CONCLUSIONS

This study showed that estimated blood loss and hemoglobin reduction were significantly lower in the cement plug group than in the empty canal group. But bone plug group did not show any difference with both empty canal and cement plug groups. Sealing the IM canal or leaving it open did not change the bleeding into the drain, transfusion rate, and postoperative pain between groups. Based on these findings, sealing the IM canal with a cement plug might be recommended to diminish bleeding during TKA despite similar transfusion rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Tourniquetless Total Knee Arthroplasty: History, Controversies, and Technique

We present a literature review with technique for tourniquetless TKA for surgeons interested in transitioning away from the tourniquet. Tourniquet use provides a bloodless field and improved visualization with decreased intraoperative blood loss, but the arguments for tourniquet use of improved cement fixation and decreased overall blood loss have not been supported by the literature. Regarding recovery, tourniquetless TKA has demonstrated less postoperative pain and improved knee function. There is also the potential for patient harm with tourniquet use. The process of tourniquetless TKA begins preoperatively with anemia screening and treatment. Tranexamic acid decreases the overall blood loss and blood transfusion risk. We recommend preemptive analgesia. The surgery is performed with the knee flexed for a near bloodless field. For cementation, the knee irrigation removes lipids from the exposed bone along with meticulous cement technique. Tourniquetless TKA is able to be safely performed on a routine basis and brings potential benefits to the patient with no evident increased risk in comparison to tourniquet use.