The effect of tourniquet uses on total blood loss, early function, and pain after primary total knee arthroplasty: a prospective, randomized controlled trial

The tourniquet's effects on skeletal muscle during total knee arthroplasty

This study investigates the impact of perioperative tourniquet on skeletal muscle cells during total knee arthroplasty (TKA) and its effects on the gene expression of apoptotic, inflammatory, and angiogenic pathways. The randomized controlled trial included 44 patients undergoing TKA. The patients were randomized to undergo surgery with (n = 23) or without (n = 21) tourniquet. The tourniquet was inflated before skin incision and deflated before wound closure in the tourniquet group. Biopsies from the lateral vastus muscle were obtained from both groups before wound closure and 8 weeks after surgery. The messenger ribonucleic acid (mRNA) expression and protein levels of angiopoietin-like 4 (ANGPTL4), Hypoxia-inducible Factor 1α, and Vascular Endothelial Growth Factor Alpha (VEGF-A) in the biopsies were examined by reverse transcription-quantitative polymerase chain reaction and tissue microarray, respectively. Differences in mean values (ΔCt for mRNA expression and staining positivity for protein expression) were compared with t-tests. The apoptotic marker BID and the angiogenic marker VEGF-A were significantly lower in the tourniquet group compared to the control group (p = 0.03, p = 0.047). However, there was a significant upregulation of VEGF-A 8 weeks after surgery in the tourniquet group compared to perioperative biopsies (p = 0.002), indicating persistent changes. A significant upregulation in protein expression of the angiogenic marker ANGPTL4 was found perioperatively in the tourniquet group (p = 0.02). Our results demonstrate that the angiogenic gene expression is significantly altered by the tourniquet, the effects of which might contribute to postoperative interstitial edema, increased pain, and decreased muscle strength. These effects could lead to delayed rehabilitation and ultimately reduced patient satisfaction after TKA.

Can We Forgo the Use of Tourniquets in Total Knee Arthroplasty?

Objective  To analyze whether there is more bleeding in patients undergoing total knee arthroplasty (TKA) without using a tourniquet. The secondary objectives were to analyze the operative time, the length of hospital stay, the need for transfusion, and the complication rate. Methods  The present is a retrospective study through the analysis of medical records. The patients were divided into two groups: TKA with and without the use of a tourniquet. Reductions in the levels of hemoglobin and packed cell volume 24 h and 48 h after surgery, the operative time, the length of hospital stay, the need for transfusion, and the rate of complications up to 6 months postoperatively were compared between the groups. Results  During the period analyzed, 104 patients underwent TKA, and 94 were included in the study. There were no differences between the groups regarding the mean values of hemoglobin and packed cell volume before surgery ( p  = 0.675 and p  = 0.265), 24 h ( p  = 0.099 and p  = 0.563), and 48 h ( p  = 0.569 and p  = 0.810) after the procedure. Neither were there differences between the groups in terms of the operative time and the length of hospital stay ( p  = 0.484 and p  > 0.05). Moreover, there were no differences regarding the need for transfusion and the complication rate. Conclusion  It is possible to forgo the use a tourniquet in TKA without a significant change in hemoglobin and packed cell volume levels 24 h and 48 h after surgery when compared with the group using a tourniquet. There were no significant differences in the total operative time, length of stay, need for transfusion, and complication rate.

Characterizing patient factors, perioperative interventions, and outcomes associated with inpatients falls after total knee arthroplasty

INTRODUCTION

Mechanical falls represent a potential adverse event after total knee arthroplasty (TKA) and may introduce further injury and delay postoperative recovery. This study aimed to identify patient characteristics associated with inpatient falls, to determine the impact of inpatient falls on surgical outcomes following TKA, and to describe the relationship between tourniquet and/or adductor canal block (ACB) use and fall rates.

METHODS

Patients undergoing primary, elective TKA at a single institution between 2018 and 2022 were retrospectively analyzed. Patients were stratified into groups based on whether they sustained a postoperative inpatient fall or not. Perioperative characteristics, lengths of stay (LOS), rates of 90-day readmissions, and revisions were compared, and fall characteristics were described. Subanalysis was conducted comparing fall incidence based on tourniquet and/or ACB use.

RESULTS

In total 6472 patients were included with 39 (0.6%) sustaining falls. Falls most commonly occurred on postoperative days one (43.6%) and two (30.8%), and were most commonly due to loss of balance (41.9%) or buckling (35.5%). Six (15.4%) fall patients sustained minor injuries, and one (2.6%) sustained major injury (malleolar fracture requiring non-operative orthopaedic management). The LOS (3.0 ± 1.5 vs 2.3 ± 1.5 days, p = 0.002) and all-cause revision rates at latest follow-up (10.3% vs. 2.0%, p = 0.008) were significantly higher in the fall group. Falls were comparable across subgroups based on tourniquet and/or ACB use (p = 0.429).

CONCLUSION

Patients who fell had a longer LOS and higher revision rate postoperatively. Rates of inpatient falls were comparable regardless of tourniquet and/or ACB use. Concern for inpatient falls should not influence surgeons when considering the use of tourniquets and/or ACBs, though well-designed, large-volume, prospective randomized studies are warranted to better understand this relationship.

Computational screening of biomarkers and potential drugs for arthrofibrosis based on combination of sequencing and large nature language model

Background

Arthrofibrosis (AF) is a fibrotic joint disease resulting from excessive collagen production and fibrous scar formation after total knee arthroplasty (TKA). This devastating complication may cause consistent pain and dramatically reduction of functionality. Unfortunately, the conservative treatments to prevent the AF in the early stage are largely unknown due to the lack of specific biomarkers and reliable therapeutic targets.

Methods

In this study, we extracted1782 fibrosis related genes (FRGs) from 373,461published literature based on the large natural language processing models (ChatGPT) and intersected with the 2750 differential expressed genes (DEGs) from mRNA microarray (GSE135854). A total of 311 potential AF biomarker genes (PABGs) were obtained and functional analysis were performed including gene ontology (GO) annotation and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. Subsequently, we accomplished validation in AF animal models with immobilization of the unilateral knee joints of 16 rabbits for 1-week, 2-weeks, 3-weeks and 4-weeks. Finally, we tested the biomarkers in a retrospective cohort enrolled 35 AF patients and 35 control group patients.

Results

We identified G-protein-coupled receptor 17 (GPR17) as a reliable therapeutic biomarker for AF diagnosis with higher AUC (0.819) in the ROC curve. A total of 21 potential drugs targeted to GPR17 were screened. Among them, pranlukast and montelukast have achieved therapeutic effect in animal models. In addition, we established an online AF database for data integration (https://chenxi2023.shinyapps.io/afdbv1).

Conclusions

These results unveiling therapeutic biomarkers for AF diagnosis, and provide potential drugs for clinical treatment.

The translational potential of this article

Our study demonstrated that GPR17 holds significant promise as a potential biomarker and therapeutic target for arthrofibrosis. Moreover, pranlukast and montelukast targeted to GPR17 that could be instrumental in the treatment of AF.

Effect of intravenous low-dose norepinephrine on blood loss in non-tourniquet total knee arthroplasty under general anesthesia: a randomized, double-blind, controlled, single-center trial

OBJECTIVE

This prospective trial aimed to evaluate the effects of low-dose intravenous norepinephrine (NE) on intraoperative blood loss and bleeding from osteotomy sites during non-tourniquet total knee arthroplasty (TKA) under general anesthesia.

METHODS

A total of 120 patients who underwent TKA between December 2020 and May 2022 were enrolled and randomly assigned to the intravenous low-dose NE Group (NE Group) or the control group (C Group). During surgery, NE Group received 0.05-0.1 μg/(kg min) of NE intravenously to raise and maintain the patient's mean arterial pressure (MAP). C Group received the same dose of saline as placebo. Intraoperative blood loss, bleeding score at osteotomy sites, Δlactate levels (Lac), postoperative complications, and transfusion rate during hospitalization were compared between groups.

RESULTS

Intraoperative and osteotomy blood loss was significantly lower in the NE Group than in the C Group (P < 0.001). No significant difference was observed in ΔLac between groups (P > 0.05). There was no significant difference in complications between the groups 3 days after surgery (P > 0.05). In addition, there was no significant difference in blood transfusion rates between the two groups during hospitalization (P > 0.05).

CONCLUSION

In non-tourniquet TKA under general anesthesia, low-dose intravenous NE safely and effectively reduced intraoperative blood loss and provided a satisfactory osteotomy site while maintaining a higher MAP.

Blood-conserving and therapeutic efficacy of intravenous tranexamic acid at different time points after primary total knee arthroplasty with tourniquet application: a randomised controlled trial

BACKGROUND

The use of a tourniquet in combination with tranexamic acid (TXA) not only ensures clear vision, reduces intraoperative blood loss and shortens operative time but also improves cement-bone inter-digitation in total knee arthroplasty (TKA). However, there is no proof whether the blood flow blocking effect of tourniquet affects the antifibrinolytic effect of TXA, and the optimal timing of TXA administration is still unclear. Therefore, this study aims to investigate the effect of the first dose of TXA administered intravenously before tourniquet compression and release in TKA on perioperative blood loss and therapeutic efficacy in patients.

METHODS

In this double-blind trial, 90 patients undergoing primary TKA were randomised into 2 groups: Group A, patients received intravenous TXA 10 min before tourniquet compression (20 mg/kg) and 3, 6 and 24 h later (10 mg/kg), and Group B, patients were treated the same as those in Group A but received intravenous TXA before tourniquet release. The primary outcomes were changes in blood loss, haemoglobin and haematocrit. Secondary outcomes included operation and tourniquet times, blood transfusion rate, subcutaneous petechiae and circumferential changes in the operated limb, visual analogue scale (VAS) score, hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction.

RESULTS

No statistically significant difference was found between the 2 groups with regard to age, sex, weight, body mass index (BMI), Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet times, transfusion rate, knee circumference, preoperative HSS, or VAS score (P:n.s.). There was no significant difference in intraoperative blood loss (IBL) (52.7 ml vs. 63.4 ml, P = 0.07), hidden blood loss (HBL) (91.4 ml vs. 119.9, P = 0.4) or total blood loss (TBL) (144.1 ml vs. 183.3 ml, P = 0.72) between Groups A and B. Haemoglobin, haematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was not statistically significant (P:n.s.). There was no significant difference in subcutaneous ecchymosis incidence, knee swelling rate, HSS score, VAS score, LOS postoperatively, complication rate or patient satisfaction (P:n.s.).

CONCLUSION

TXA was administered intravenously prior to tourniquet compression could effectively reduce blood loss in patients who had undergone total knee arthroplasty. However, there was no significant difference in knee swelling rate, subcutaneous bruising and petechiae incidence, knee function, complication rate or satisfaction between patients who TXA was given intravenously before tourniquet compression and release in primary TKA.

Tourniquet use benefits to reduce intraoperative blood loss in patients receiving total knee arthroplasty for osteoarthritis: An updated meta-analysis with trial sequential analysis

PURPOSE

The efficacy and safety of tourniquets use during total knee arthroplasty (TKA) in patients with osteoarthritis remain debated. This updated systematic review and meta-analysis aimed to further evaluate the role of tourniquets use in patients undergoing TKA for knee osteoarthritis by introducing trial sequential analysis.

METHODS

PubMed, Embase, and the Cochrane Library were searched. We used the Cochrane risk of bias tool for quality assessment. Statistical heterogeneity across studies was evaluated using Cochran's Q and I2 statistic. Meta-analysis was performed using Stata/SE 14.0, and trail sequential analysis was performed using TSA software version 0.9.5.10 Beta. In addition, qualitative summary was also used to describe results.

RESULTS

15 randomized controlled trials (RCTs) involving 1202 patients were included in the meta-analysis. The pooled results showed that tourniquet use during TKA significantly reduced intraoperative blood loss (mean difference (MD)= -123.84, 95% confidence interval (CI): -163.37 to -84.32, p < .001)and shortened operation time (MD = -4.71, 95% CI: -7.6 to -1.82, p = .001), but there were no significant differences in postoperative blood loss, calculated blood loss, total blood loss, transfusion rate (p = .939), and deep venous thrombosis (DVT) rate between the tourniquet and no-tourniquet groups. TSA confirmed that the result of operation time was false positive, but the results of other outcomes were conclusive. The results of qualitative summary showed conflicting findings in terms of pain, range of motion (RoM) and swelling ratio between the two groups.

CONCLUSIONS

Tourniquet use in patients receiving TKA for osteoarthritis benefits to reduce intraoperative blood loss but has no effect on postoperative blood loss, calculated blood loss, total blood loss, operation time, transfusion rate, and DVT rate. In addition, it remains unclear the difference between the tourniquet and non-tourniquet groups in terms of pain, RoM and swelling ratio.

Tourniquets can further reduce perioperative blood loss in patients on dexamethasone and tranexamic acid during cemented total knee arthritis: a single-center, double-blind, randomized controlled trial

BACKGROUND

Multiple doses of dexamethasone and tranexamic acid can inhibit postoperative inflammation and reduce fibrinolysis and perioperative blood loss in total knee arthroplasty. In this single-center, double-blind, randomized clinical trial, the aim was to investigate whether applying a tourniquet to patients on dexamethasone and tranexamic acid could further reduce perioperative blood loss.

MATERIALS AND METHODS

Patients who underwent cemented total knee arthroplasty at our hospital were randomized to receive a tourniquet (n = 71) or not (n = 70) during the procedure. All patients received multiple doses of dexamethasone and tranexamic acid perioperatively. The primary outcome was perioperative blood loss, while secondary outcomes were surgery duration, postoperative laboratory indices of inflammation and fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, and complications.

RESULTS

Using a tourniquet was associated with significantly lower intraoperative blood loss (P < 0.001) and total blood loss (P = 0.007) as well as significantly shorter surgery duration (P < 0.001). In contrast, the tourniquet did not significantly affect hidden blood loss, postoperative inflammation or fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, or complications.

CONCLUSIONS

The results of this randomized clinical trial demonstrate that applying a tourniquet during cemented total knee arthroplasty to patients receiving multiple doses of dexamethasone and tranexamic acid can further reduce perioperative blood loss without increasing the risk of inflammation, fibrinolysis, or other complications. Thus, it is advised to use tourniquets combined with dexamethasone and tranexamic acid to reduce perioperative blood loss and avoid tourniquet-related adverse events.

LEVEL OF EVIDENCE

Therapeutic Level I. Trial registration Chinese Clinical Trail Registry, ChiCTR2200060567. Registered 5 June 2022-retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=171291.

Optimized Tourniquet Use in Primary Total Knee Arthroplasty: A Comparative, Prospective, and Randomized Study

BACKGROUND

The results of recent studies investigating tourniquet (TNQ) use for knee arthroplasty are controversial. Therefore, this study aimed to compare patients undergoing total knee arthroplasty who did not have a TNQ to those in whom an optimized TNQ protocol was applied.

METHODS

We prospectively evaluated 127 patients who had knee osteoarthritis who had undergone total knee arthroplasty and randomized them into two groups: "without TNQ" and "optimized TNQ" (TNQ inflation before skin incision, deflation after cementing, with pressure one hundred millimeters of mercury above the systolic blood pressure, and without articular suction drain usage). The means of surgery and TNQ duration, blood loss, number of blood transfusions, degree of pain, edema, range of motion (ROM), functional score over time, and postoperative complications were compared between the groups. Statistical significance was set at P < .05.

RESULTS

No significant differences were found in terms of surgical timing, blood loss, thigh and knee pain, edema, ROM, functional scores, and complications between the "without TNQ" and "optimized TNQ" groups.

CONCLUSION

The use of an optimized TNQ in primary total knee arthroplasty presents similar clinical results to surgery without a TNQ and did not increase the incidence of postoperative complications. Its use allowed surgery to occur with the benefits of a clean and dry surgical field provided by TNQ without increasing procedure-related comorbidities.

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.

Tourniquet use during primary total knee arthroplasty-a survey of Irish orthopaedic surgeons in 2022

BACKGROUND

Tourniquet use during primary total knee arthroplasty is a debated topic in the literature with no consensus on its optimal use.

AIM

To analyse current tourniquet practice amongst Irish orthopaedic surgeons performing primary total knee arthroplasty surgery. To evaluate if there has been a shift in practice in recent years and to explore potential reasons behind this.

METHODS

An eleven-question online survey was developed using the online platform SurveyMonkey. This was distributed by email to Irish orthopaedic surgeons via the Irish Institute of Trauma and Orthopaedic Surgery.

RESULTS

Fifty responses were included in the final analysis of this study. Eighteen (36%) respondents reported changing their tourniquet use in the past 5 years. Thirty-one (62%) respondents reported inflating the tourniquet for the entire case, with the remaining never applying a tourniquet (n = 6, 12%), applying a tourniquet but not routinely inflating it (n = 3, 6%), or inflating the tourniquet only during cementation (n = 5, 10%). The number of years of experience as a consultant appeared to impact tourniquet use in a bimodal pattern.

CONCLUSION

While the majority of Irish orthopaedic surgeons in this survey inflate a tourniquet for the entire surgical procedure, there is a definite shift towards reduced tourniquet use compared to previous Irish, UK, and American surveys.

Measurement of tissue oxygen saturation during arthroscopic surgery of knee with a tourniquet

BACKGROUND

Tourniquets provide better tissue visibility during arthroscopic surgery. However, multiple postoperative adverse events associated with ischemia may be caused by excessive inflation pressure and duration. We aimed to evaluate the degree of tourniquet-induced ischemia using a noninvasive continuous real-time monitoring method and the relationship between changes in tissue oxygen saturation (StO2) and blood biochemical markers of ischemic injuries in patients undergoing arthroscopic knee surgery.

METHODS

This was a prospective observational study using near-infrared spectroscopy (NIRS). Data were collected from 29 consecutive patients who underwent arthroscopic procedures. Twenty-five patients underwent anterior cruciate ligament reconstruction, and four underwent meniscal repair. We investigated tourniquet-induced changes in StO2, monitored using NIRS, and blood biochemical markers of ischemic injuries.

RESULTS

A significant decrease in the mean StO2 from the baseline was observed during tourniquet inflation in the operative legs. The average decrease in the mean StO2 was 58%. A comparison of mean StO2 between the nonoperative and operative legs before tourniquet deflation showed that mean values of StO2 in the operative legs were significantly lower than those in the nonoperative legs. No significant clinical relationships were observed between changes in StO2 and blood biochemical markers of ischemic injuries (creatine kinase) (p = 0.04, r = 0.38) or tourniquet duration (p = 0.05, r = 0.366).

CONCLUSIONS

Our results demonstrated that StO2 could be used to evaluate tissue perfusion in real time but did not support the hypothesis that StO2 is a useful method for predicting the degree of tourniquet-induced injury during arthroscopic knee surgery.

Fat Necrosis Following Application of a Tourniquet During Total Knee Arthroplasty

A 60-year-old female underwent a right total knee arthroplasty but developed postoperative pain, swelling, and decreased knee range of motion. An ultrasound scan showed findings suggestive of fat necrosis at the site of previous tourniquet application. Following regular reviews, intensive physiotherapy, and analgesia, symptoms only started to resolve 5 months following the primary surgery. Fat necrosis of the thigh is highly uncommon following the application of tourniquets during total knee arthroplasty. This case was treated successfully without complications using nonoperative measures.

Tourniquet Use Is Associated With Reduced Blood Loss and Fewer Reoperations in Aseptic Revision Total Knee Arthroplasty

BACKGROUND

Although tourniquet use in primary total knee arthroplasty (TKA) has been widely studied, the outcomes associated with tourniquet use in revision TKA (rTKA) remains relatively unexplored. This study investigates surgical outcomes and patient satisfaction in association with tourniquet use during aseptic rTKA.

METHODS

We retrospectively reviewed all patients who underwent rTKA for aseptic causes at our institution from 2011 to 2020. Patients were separated into 2 cohorts based on tourniquet inflation during the procedure. Outcomes of interest included estimated blood loss, change in hemoglobin, surgical time, length of stay, reoperation rate, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores.

RESULTS

Of the 1212 patients included, 1007 (83%) underwent aseptic rTKA with the use of a tourniquet and 205 (17%) without the use of a tourniquet. The mean tourniquet inflation time was 93.0 minutes (standard deviation 33.3 minutes). Blood loss was significantly less for patients in the tourniquet cohort as measured through estimated blood loss (224.1 vs 325.1 mL, P < .001) and change in preoperative to postoperative hemoglobin (1.75 vs 2.04 g/dL, P < .001). There were no statistical differences in surgical time (P = .267) and length of stay (P = .206) between the 2 groups. The reoperation rate was significantly greater for patients who did not have a tourniquet utilized (20.5% vs 15.0%, P = .038). Delta improvement in KOOS, JR scores from baseline to 3 months postoperatively did not statistically differ between the 2 cohorts (P = .560).

CONCLUSION

Although delta improvements in KOOS, JR scores were similar for both cohorts, patients who did not have a tourniquet inflated during aseptic rTKA had increased blood loss and were more likely to undergo subsequent reoperation compared to patients who did.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

Purpose

The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA.

Methods

A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate.

Results

14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7–5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1–3.1) with an OR of 1.9 (95% CI = 1.1–3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12–0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4–5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10–0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7–9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50–19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60–3.60, p = 0.36) did not differ between the two groups.

Conclusion

Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use.

Level of evidence

meta-analysis, Level II.

Peripheral nerves in the tibial subchondral bone : the role of pain and homeostasis in osteoarthritis

Osteoarthritis (OA) is a highly prevalent degenerative joint disorder characterized by joint pain and physical disability. Aberrant subchondral bone induces pathological changes and is a major source of pain in OA. In the subchondral bone, which is highly innervated, nerves have dual roles in pain sensation and bone homeostasis regulation. The interaction between peripheral nerves and target cells in the subchondral bone, and the interplay between the sensory and sympathetic nervous systems, allow peripheral nerves to regulate subchondral bone homeostasis. Alterations in peripheral innervation and local transmitters are closely related to changes in nociception and subchondral bone homeostasis, and affect the progression of OA. Recent literature has substantially expanded our understanding of the physiological and pathological distribution and function of specific subtypes of neurones in bone. This review summarizes the types and distribution of nerves detected in the tibial subchondral bone, their cellular and molecular interactions with bone cells that regulate subchondral bone homeostasis, and their role in OA pain. A comprehensive understanding and further investigation of the functions of peripheral innervation in the subchondral bone will help to develop novel therapeutic approaches to effectively prevent OA, and alleviate OA pain.

Cite this article: Bone Joint Res 2022;11(7):439–452.

The mid-term and long-term effects of tourniquet use in total knee arthroplasty: systematic review

Purpose

A tourniquet is routinely used during total knee arthroplasty (TKA) to reduce intra-operative hemorrhage, though surgery without a tourniquet is becoming popular. To address concerns about the effect of blood at cement interfaces on long-term implant stability, we conducted a systematic review among patients undergoing total knee arthroplasty to determine if TKA with a tourniquet, compared to TKA without a tourniquet or with reduced tourniquet duration, is associated with better mid-term and long-term implant stability.

Methods

A literature search was conducted without language restriction in PubMed, Cochrane database and Web of Science from conception to 17th March, 2021. Prospective cohorts, randomized and observational, that compared tourniquet use with a control group, followed patients for 3 months or more and reported outcomes concerning implant stability, limb function, pain and inflammation. Article selection, quality assessment according to the Revised Cochrane risk assessment scale and Newcastle Ottawa Scale, and data extraction were conducted in duplicate. PROSPERO: CRD42020179020.

Results

The search yielded 4868 articles, from which 16 randomized controlled trials (RCT) and four prospective cohort studies, evaluating outcomes of 1884 knees, were included. Eleven RCTs were evaluated to be low overall risk of bias, five RCTs had some concerns and four cohort studies were good quality. Few studies showed benefits of tourniquet use in mid-term implant stability (1/6), pain (1/11) and limb inflammation (1/5), and long-term implant stability (1/1). One study reported a significantly improved range of motion (1/14) while another reported significantly reduced quadriceps strength (1/6) in the tourniquet group. The remaining studies reported non-significant effect of tourniquet use.

Conclusion

Although few studies indicated benefits of tourniquet use in mid-term pain, limb inflammation, implant loosening and function, and long-term implant loosening, the majority of studies report no significant advantage of tourniquet use in total knee arthroplasty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00471-1.

Comparison of serum inflammatory indicators and radiographic results in MAKO robotic-assisted versus conventional total knee arthroplasty for knee osteoarthritis: a retrospective study of Chinese patients

BACKGROUND

The purpose of this study was to compare the serum inflammatory indicators and radiographic results of conventional manual total knee arthroplasty (CM-TKA) with those of MAKO-robotic assisted total knee arthroplasty (MA-TKA).

METHODS

We retrospectively analysed 65 patients with knee osteoarthritis who underwent unilateral TKA from December 2020 to November 2021 in our department, which included 34 patients who underwent MA-TKA and 31 patients who underwent CM-TKA. The tourniquet time and estimated blood loss (EBL) were compared between the two groups. Knee function was evaluated using range of motion (ROM), functional score and pain score. Leukocytes, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), creatine kinase (CK), and neutrophil-to-lymphocyte ratio (NLR) were recorded at 3 time points (preoperative, and on the first and third postoperative days). The hip-knee-ankle angle (HKA) and the femoral and tibial component angles in the coronal and sagittal planes were used for postoperative radiographic evaluation.

RESULTS

The postoperative MA-TKA group had less EBL (496.9 ± 257.8 vs. 773.0 ± 301.3 ml, p < 0.001). There was no significant difference in knee function scores at 6 weeks postoperatively (p > 0.05). IL-6 levels were significantly lower in the MA-TKA group on the 1st postoperative day (11.4 (5.2, 21.0) vs. 24.6 (86.3, 170.8), p = 0.031). This difference in inflammatory indices became more pronounced at 72 hours after the operation because CRP, ESR, IL-6, and CK values were significantly lower in the MA-TKA group on the 3rd postoperative day (72 h) (p < 0.05). Postoperative radiographic examinations performed 2 days after the MA-TKA group suggested that only 2 cases of HKA had outlier values, which was remarkably better than the 12 cases found in the CM-TKA group (5.9% vs. 38.7%, p < 0.001). The frontal femoral component was significantly closer to the expected value of 90° in the MA-TKA group (90.9 (90.5, 92.3) vs. 92.4 (91.3, 93.7), p = 0.031). The remaining imaging evaluation parameters were not significantly different between the two groups (p > 0.05).

CONCLUSIONS

In Chinese patients with OA, there was a milder systemic inflammatory response in the early postoperative period after MA-TKA compared to that of CM-TKA, as well as better radiographic outcomes. However, the tourniquet time was prolonged, and no advantages were observed in terms of functional score or pain score in the short-term follow-up.

Blood Management Following Total Joint Arthroplasty in an Aging Population: Can We Do Better?

BACKGROUND

To evaluate the transfusion rates for octogenarians and nonagenarians following total knee and hip arthroplasty (TKA, THA), we compared transfusion rates and associated risk factors among sexagenarians, septuagenarians, octogenarians, and nonagenarians.

METHODS

This retrospective cohort study included 13,603 sexagenarians, 9796 septuagenarians, 2706 octogenarians, and 158 nonagenarians that received a primary, unilateral THA or TKA between 2016 and 2020 at a high-volume institution. Using multivariable logistic regression analysis, the study analyzed risk factors for postoperative transfusions including use of tranexamic acid (TXA) and compared preoperative and postoperative hemoglobin (Hgb) levels and the drop in Hgb.

RESULTS

Nonagenarians had significantly higher transfusion rates (THA 25.5%, TKA 26.7%) than octogenarians (THA 9.9%, TKA 9.2%), septuagenarians (THA 3.3%, TKA 4.5%), and sexagenarians (THA 1.9%, TKA 2.9%) (P < .01). Significant risk factors for transfusion requirement following THA were American Society of Anesthesiologists level III (odds ratio [OR] 5.3, P < .01) and American Society of Anesthesiologists level IV (OR 8.0, P = .01), nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), longer duration of surgery (OR 1.0, P < .01), and hepatopathy (OR 3.1, P < .01). Significant risk factors following TKA were nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01; combined: OR 0.2, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), and longer surgery time (OR 1.0, P < .01).

CONCLUSION

The strongest independent risk factors for increased transfusion rates among octogenarians and nonagenarians were lack of TXA application and lower preoperative Hgb levels. Routine TXA application and preoperative patient optimization are recommended to reduce transfusion rates in patients aged 80+.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty

Background

Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs).

Material and methods

Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides.

Results

The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in “exposure” (9.5 vs 16.5 minutes) and “closure” steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides.

Conclusion

Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical “exposure” and “closure” were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

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.

The effect of tourniquet application on the morphology and function of quadriceps in patients undergoing total knee arthroplasty: study protocol for a single-blind randomized controlled trial

Background

Tourniquet is currently widely used in total knee arthroplasty to reduce intraoperative blood loss. The academic view of tourniquet application in TKA is now in dispute. Some scholars argue that tourniquet may cause quadriceps injury and bring extra side effects, so they oppose the application of tourniquet. Others find that tourniquet application has no significant adverse impact on TKA patients. Regarding its advantages in reducing intraoperative blood loss, they advocate the regular application of tourniquet in TKA. Quadriceps injury is considered the main cause of tourniquet side effects. There are now many high-quality trials about tourniquet application in TKA but few of them concentrate on quadriceps morphology and function.

Methods

A prospective, single-blind, randomized controlled trial will be adopted. The target sample is 130. Patients who meet the eligibility criteria will be randomly allocated to the tourniquet group and non-tourniquet group. The primary outcome is quadriceps thickness evaluated by ultrasound test. Secondary outcomes include quadriceps stiffness, rehabilitation outcomes, operation time, intraoperative and postoperative blood loss, blood transfusion rate, thigh circumference, VAS score, opioid consumption, d-dimer and C-reactive protein level in the serum, knee function score, postoperative satisfaction score, and complications.

Discussion

This proposed study will contribute to improve evidence of tourniquet application in total knee arthroplasty. This will be a high-quality single-blind randomized controlled trial with a sufficient sample size and strict study design. It will investigate the effects of tourniquet application especially on the morphology and function of quadriceps in patients undergoing total knee arthroplasty and offer advice for tourniquet application in clinical practice.

Trial registration

Chinese Clinical Trial Registry ChiCTR2000035097. Registered on 31 July 2020

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.

Improving the cementation of the tibial component in knee arthroplasty : a study of four techniques in the cadaver

AIMS

The main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray.

METHODS

In order to determine the best tibial tray cementation technique, we applied cement to 40 cryopreserved donor tibiae by four different techniques: 1) double-layer cementation of the tibial component and tibial bone with bone restrictor; 2) metallic cementation of the tibial component without bone restrictor; 3) bone cementation of the tibia with bone restrictor; and 4) superficial bone cementation of the tibia and metallic keel cementation of the tibial component without bone restrictor. We performed CT exams of all 40 subjects, and measured cement layer thickness at both levels of the resected surface of the epiphysis and the endomedular metaphyseal level.

RESULTS

At the epiphyseal level, Technique 2 gave the greatest depth compared to the other investigated techniques. At the endomedular metaphyseal level, Technique 1 showed greater cement penetration than the other techniques.

CONCLUSION

The best metaphyseal cementation technique of the tibial component is bone cementation with cement restrictor. Additionally, if full tibial component cementation is to be done, the cement volume used should be about 40 g of cement, and not the usual 20 g. Cite this article: Bone Joint Res 2021;10(8):467-473.

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 in primary total knee arthroplasty is associated with a hypercoagulable status: a prospective thromboelastography trial

STUDY DESIGN

Prospective study.

PURPOSE

The main purpose of this study was to investigate whether the use of a tourniquet changes the blood coagulation state following primary total knee arthroplasty (TKA) by means of conventional coagulation tests and thromboelastography (TEG) analyses.

METHODS

A total of 154 patients who underwent primary unilateral TKA from January 2018 to October 2020 were enrolled. Seventy-nine patients were randomized into a tourniquet group, and 75 were randomized into a no-tourniquet group. Demographic data, surgical time, intra-operative blood loss, transfusion rate, and wound complications were collected. Complete blood count, conventional coagulation tests, and TEG were performed the day before surgery, one day after surgery, three days after surgery, and seven days after surgery. Lower extremity Doppler ultrasound was performed the day before surgery and seven days after surgery.

RESULTS

The baseline characteristics of the patients were similar between the two groups. Hidden blood loss, transfusion rate, and wound complications were similar between the two groups, but the intra-operative blood loss of the tourniquet group was lower than that of the no-tourniquet group. The calculated total blood loss of the tourniquet group was higher than that of the no-tourniquet group. In terms of conventional coagulation tests and TEG, the tourniquet group had higher values of fibrin degradation products, D-dimer, maximum amplitude, and coagulation index (p < 0.001). The incidence of deep vein thrombosis (DVT) in the tourniquet group was higher than that in the no-tourniquet group (21.5% compared with 8%; p = 0.019).

CONCLUSION

The application of a tourniquet during TKA significantly increases the amount of calculated total blood loss and does not decrease the post-operative transfusion rate. Using a tourniquet in routine TKA exacerbates the early post-operative hypercoagulable status together with a higher incidence of below-knee asymptomatic DVT observed via conventional coagulation tests, TEG, and ultrasonic Doppler.

Tourniquet use in lower limb trauma and fracture surgery

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.

Comparison of Intravenous and Topical Dexamethasone for Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Study of Effects on Dexamethasone Administration Route and Enhanced Recovery

BACKGROUND

The optimal route for dexamethasone (DEX) administration regimen for patients undergoing primary TKA has not been investigated. This study aims to determine whether intravenous and topical DEX provide different clinical effects in patients with TKA.

METHODS

In this double-blinded, placebo-controlled trial, 90 patients undergoing primary TKA were randomized to intravenous DEX group (n = 45) or topical DEX group (n = 45, DEX applied in anesthetic cocktail for periarticular injection). The primary outcome was postoperative VAS pain score and morphine consumption. Secondary outcomes were included knee swelling, knee flexion, and extension angle, Knee Society Score (KSS), and postoperative hospital stays. Tertiary outcomes assessed the blood-related metrics, including inflammatory biomarkers and fibrinolysis parameters. Finally, nausea and vomiting and other adverse events were compared.

RESULTS

The topical administration of DEX provide lower pain score at 2h, 8h, 12h at rest (P < .05) and 12h, 24h with activity (P < .05), and less knee swelling in the first postoperative day (P < .05), while intravenous DEX was more effective in decreasing blood inflammatory biomarkers, including C-reactive protein (CRP) at postoperative 24h (P < .05) and interleukin-6 (IL-6) at postoperative 24h, 48h (P < .05), and reducing postoperative nausea (P < .05) for patients receiving TKA. However, there was no significant difference in knee flexion and extension angle, KSS, postoperative hospital stays, and complications occurrence (P > .05) between intravenous and topical DEX after TKA.

CONCLUSION

Topical administration of DEX provided better clinical outcomes on postoperative pain management and knee swelling early after TKA, while intravenous DEX was more effective in decreasing blood inflammatory biomarkers and preventing postoperative nausea.

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.