Factors affecting wound ooze in total knee replacement

Effects of Tourniquet Application on Faster Recovery after Surgery and Ischemia-Reperfusion Post-Total Knee Arthroplasty, Cementation through Closure versus Full-Course and Nontourniquet Group

Pneumatic tourniquets are used in total knee arthroplasty (TKA) for surgical field visualization and improved cementation; however, their use is controversial. This study aimed to assess the effects of tourniquet application on faster recovery post-TKA. Our hypothesis was that inflammation and limb function would be similar with different tourniquet applications. A prospective randomized double-blinded trial assessed tourniquets effects on postoperative pain, swelling, and early outcome in TKA. In present study, 50 TKAs were enrolled in each group as follows: full course (FC), cementation through closure (CTC), and no tourniquet (NT), CTC as treatment group while FC and NT as control groups. Topical blood samples of 3 mL from the joint cavity and drainage bags were obtained at special time point. At last, all samples such as tumor necrosis factor-a (TNF-a), C-C motif chemokine ligand 2 (CCL2), pentraxin 3 (PTX3), prostaglandin E2 (PGE2), superoxide dismutase 1 (SOD1), and myoglobin (Mb) were detected by ELISA. Active and passive range of motion (ROM) values, pain score by the visual analog scale (VAS), change of thigh circumference were recorded at special time point as well. In topical blood, the change of inflammatory factors, such as TNF-a, PTX3, CCL2, PGE2, SOD1, and Mb, was lower in CTC and NT groups than in FC group (p < 0.01 and 0.05). Although VAS and ROM were comparable preoperatively in three groups (p > 0.05), the perimeter growth rate was lower, pain scores (VAS) were reduced, and ROM values were improved in CTC and NT groups compared with FC group at T4, T5, and T6 postoperatively (p < 0.01 and 0.05). Improved therapeutic outcome was observed in the CTC group, indicating patients should routinely undergo TKA with cementation through closure tourniquet application.

Comparison of efficacy and safety of different tourniquet applications in total knee arthroplasty: a network meta-analysis of randomized controlled trials

OBJECTIVE

Total knee replacement (TKA) is an effective way to treat teratogenic and disabling knee diseases such as advanced osteoarthritis. Tourniquets are often used in TKA to reduce bleeding and to get a better visualization of the surgical field, while it is related to safety concerns. We did this network meta-analysis to comprehensively compare the efficacy and safety of various tourniquet application strategies.

METHOD

PubMed, Embase, Cochrane Library, CNKI, and WanFang Database were systematically searched from January 1990 to May 2020. A network meta-analysis with a frequentist framework was done to assess the relative efficacy and safety by comparing seven clinical important endpoints.

RESULTS

38 eligible studies that assessed 3007 participants who underwent TKA were included in this network meta-analysis. Tourniquet inflation before osteotomy then deflation after wound closure effectively reduce perioperative bleeding (WMD compared with control group -234.66, 95% CI [-409.19 to -60.13]), while shortening the operation time (WMD -8.98, 95%CI [-14.07 to -3.88]) and reducing postoperative complications, including DVT (OR -0.58, 95%CI [-1.19 to 0.03]) and minor wound complications (OR -1.38, 95%CI [-3.00 to 0.25]). No difference was found in the late postoperative knee pain and function outcomes.

CONCLUSIONS

Using tourniquets during the entire operation can effectively reduce blood loss, but it also can cause many safety problems, including DVTs, wound oozing, delayed healing, and serious wound complications. Tourniquet inflation before osteotomy then deflation after wound closure effectively can reduce perioperative bleeding while shortening the operation time and reducing postoperative complications, so it could be the ideal tourniquet application strategy in TKA.Key messagesThis is the first study that comprehensively compared different tourniquet application strategies to evaluate their impact on postoperative recovery following TKA, and five clinically important endpoints were assessed in this study: perioperative blood loss, operation time, postoperative pain and function, and complications.We conclude that tourniquet inflation before osteotomy then deflation after wound closure could be the ideal tourniquet application strategy in TKA.

The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive.

PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics.

Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI.

Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described.

The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available.

Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054

The 90-day Readmission Rate after Single-Bundle ACL Reconstruction Plus LET: Analysis of 2,559 Consecutive Cases from a Single Institution

The aim of the present study is to examine the readmission rate within 90 days of a cohort of patients, who underwent an arthroscopic anterior cruciate ligament (ACL) reconstruction with a lateral extraarticular tenodesis, from a single highly specialized sports traumatology department. From our institutional database, we identified 2,559 patients (78.5% males and 21.5% females, with a mean age at surgery of 30.9 ± 11.5 years) who underwent primary ACL reconstruction with the same "over-the-top" technique plus lateral extraarticular tenodesis (LET) from January 2010 to December 2017. From this count, we extracted all patients who were readmitted within 90 days and focused on causes of readmission and reoperation rate. Moreover, a multivariate logistic regression was performed to identify possible variables, such as gender, age, and concomitant meniscus surgery, which could predict the risk of early readmission. From the aforementioned cohort, 58 patients (2.27%) were readmitted within 90 days from surgery after a mean time of 31 ± 23 days. The most common cause of readmission was fever and knee swelling (0.78%), followed by superficial infection (0.63%), deep infection (0.55%), and joint stiffness (0.23%). The patients' age and meniscal lesions requiring concomitant arthroscopic treatment were found to be correlated to an increased risk of early readmission. Superficial infections were more common in female patients (odds ratio [OR] = 3.01), whereas the meniscal treatment was also a significant risk factor specifically for deep infections (OR = 3.56). In conclusion, this technique of arthroscopic ACL reconstruction with LET showed a low readmission rate within 90 days from surgery. However, patients and physicians should be aware of the risk of serious complications, such as deep and superficial infections, mostly in female patients and in cases of concurrent meniscal treatments. This is a Level IV, retrospective case series study.

Effects of tourniquet use on clinical outcomes and cement penetration in TKA when tranexamic acid administrated: a randomized controlled trial

Background

The role of a tourniquet is still controversial for patients undergoing total knee arthroplasty (TKA). Our current study was performed to determine whether the nonuse of the tourniquet combine with tranexamic acid (TXA) application in TKA patients with end-stage osteoarthritis would accelerate the perioperative recovery rate and provide enough cement mantle thickness for implant fixation.

Methods

In this prospective, randomized controlled trial, 150 end-stage knee osteoarthritis patients receiving TKA were divided into three groups: group A (tourniquet group), group B (non-tourniquet group), and group C (tourniquet in cementation group). All enrolled patients received 3 g of intravenous TXA and 1 g topical TXA. The primary outcomes included blood loss variables and transfusion values. The secondary outcomes included VAS pain score, inflammatory factors level, range of motion, HSS score, postoperative hospital stay, and complication. Furthermore, by using a digital linear tomosynthesis technique, tibial baseplate bone cement mantle thickness was measured in four zones based on the knee society scoring system.

Results

No significant difference was found among the three groups with regards to total blood loss, transfusion, and complication. However, patients in group B showed lower inflammatory factors levels, shorter length of hospital stay, better range of motion, and lower postoperative pain. No significant difference was found among the three groups in four zones in terms of bone cement mantle thickness.

Conclusions

For end-stage knee osteoarthritis patients, the absence of tourniquet did not appear to affect blood loss and cement penetration in TKA patients. Furthermore, less inflammation reaction and better knee function can be achieved without a tourniquet. We recommend no longer use a tourniquet in primary TKA for patients with end-stage osteoarthritis when TXA is administrated.

Trial registration

ChiCTR-INR-16009026.

Level of evidence

Therapeutic Level I.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Difficult primary total knee arthroplasty requiring a varus-valgus constrained implant is at higher risk of periprosthetic infection

PURPOSE

The goal of this study was to compare the risk of periprosthetic infection of a consecutive cohort of primary varus-valgus constrained (VVC) total knee arthroplasties (TKAs), with a matched 1:1 cohort of primary posterior-stabilized (PS) TKAs.

METHODS

74 primary VVC TKAs performed in 66 patients were identified and matched 1:1 with a cohort of 74 primary PS TKAs performed in 73 patients. At last follow up, patients were clinically evaluated using the Knee Society Score (KSS). Kaplan-Meier survival curves were generated to analyze survivorship using as endpoints revision for any reason, revision for periprosthetic infection and revision for mechanical failure after excluding periprosthetic infection. A multivariate logistic regression analysis was constructed to determine whether revision surgery for periprosthetic infection was influenced by patients' gender, age, surgical time and reasons for TKA (primary vs secondary osteoarthritis).

RESULTS

Demographic data were not significantly different between the two groups as regard patients' age, gender, body mass index, Charlson Comorbidity Index, reasons for replacement, and length of follow-up. Surgical time was greater in the VVC group (95.7 ± 22.5 min vs 88.6 ± 17.1 min, respectively, p = 0.032). Postoperative KSS, range of motion and radiographic data did not differ significantly between the two groups. Overall revision rate and revision rate for mechanical failure after 5 years of follow-up was not statistically different between the two groups. Considering only the revision rate due to periprosthetic infection, the risk was higher in patients with primary VVC implants (p = 0.013). The surgical time was the only factor that significantly affected the risk of revision for periprosthetic infection (OR 1.0636, CI 95% 1.0209-1.1081, p = 0.0032), whereas patients' gender, age and reason for TKA had no influence.

CONCLUSIONS

Patients and surgeons should be aware of the higher risk of periprosthetic knee infection using a VVC prosthesis. However, the present study supports the use of VVC implants in cases of difficult knee replacements, since comparable clinical outcomes and overall revision rate was found after at least 5 years of follow up.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Persistent Wound Drainage among Total Joint Arthroplasty Patients Receiving Aspirin vs Coumadin

BACKGROUND

Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJI), arguably the most dreaded complications after a total hip and knee arthroplasty (THA and TKA). The aim of this study is to identify the rates of PWD among THA and TKA patients who received aspirin (ASA) or Coumadin for postoperative venous thromboembolism (VTE) prophylaxis.

METHODS

Retrospective review of 5516 primary THA and TKA was performed. Patients with PWD were identified. Chi-square test was used to compare the incidences of PWD, 30-day VTE, and PJI at 6 months between the ASA and Coumadin groups. Multivariate regression model was used to identify independent risk factors for PWD using Charlson and Elixhauser comorbidity indexes.

RESULTS

The prevalence of PWD was 6.4% (353/5516). Patients receiving ASA had lower incidence of PWD (3.2% vs 8.5%, P < .0001) while having comparable rates of 30-day VTE (1.3% vs 1.4%, P = .722) and PJI at 6 months (1.8% vs 1.4%, P = .233) compared to those receiving Coumadin. Risk factors for PWD were diabetes (odds ratio [OR], 19.3; 95% confidence interval [CI], 11.8-23.2), rheumatoid arthritis (OR, 15.3; 95% CI, 10.8-17.2), morbid obesity (OR, 13.2; 95% CI, 9.7-17.5), chronic alcohol use (OR, 3.5; 95% CI, 1.8-5.5), hypothyroidism (OR, 1.9; 95% CI, 1.1-3.2), and Coumadin (OR, 1.7; 95% CI, 1.2-2.2).

CONCLUSION

Use of ASA is associated with significantly lower rates of PWD after THA and TKA when compared to Coumadin while being equally efficacious at preventing VTE. Coumadin was found to be an independent risk factor for PWD.

A Perioperative Small Dose of Dexamethasone Enhances Postoperative Recovery by Reducing Volume and Inflammatory Contents in Wound Drainage After Thyroid Surgery: A Double-Blinded, Randomized, Prospective Study

BACKGROUND

The aims of this study were to assess the effect of perioperative dexamethasone on postoperative thyroid surgery recovery using measures of wound drainage volume and C-reactive protein (CRP) levels and leukocyte counts.

MATERIALS AND METHODS

From January to September 2014, healthy patients, aged between 18 and 65 years, had elective thyroid surgery in the tertiary hospital. Eligible patients were randomized into either group D (dexamethasone 0.1 mg/kg IV) or group S (saline IV) after anesthesia induction. At the end of surgery, a drainage tube was placed at the thyroid bed with a negative pressure ball connected outside the wound. Drainage fluids were collected after thyroid surgery. The fluid volume and the levels of C-reactive protein and leukocyte counts inside were analyzed. All patients were followed up for 1 month.

RESULTS

The median total drainage in group D (n = 103) was 43 ml (IQR: 21-83 ml), and 68 ml (IQR: 35-104 ml) in group S (n = 111), P = 0.002. More patients in group D were discharged on postoperative day 2 (74.8% vs. 54.1%, P = 0.002). The CRP levels and leukocyte counts were much less in group D than in group S (P = 0.002 and P < 0.001, respectively). Two patients (one in each group) had wound infections 1 week after surgery that healed one additional week later.

CONCLUSIONS

One perioperative small dose of dexamethasone reduced wound drainage volume and inflammatory content after thyroid surgery, thereby possibly contributing to early recovery. The effects of dexamethasone have never been evaluated before under these conditions.

REGISTRATION NUMBER

NCT02304250 ( http://www.clinicaltrials.gov ).

Barbed suture and glue in skin closure during lower limb arthroplasty: reduced delayed discharge due to wound exudate

Objective:

The number of hip and knee replacement performed is rising, causing increased pressure for the timely management of these patients. A dry incision is considered a prerequisite for discharge. This is a retrospective cohort study comparing two treatments for skin closure during elective hip and knee arthroplasty.

Methods:

A barbed monofilament absorbable 3.0 subcuticular suture (Quill), with the additional surface application of n-butyl-2-cyanoacrylate glue, was used for the study group and metal clips or a smooth monofilament absorbable 3.0 subcuticular suture (Monocryl) for the control group. Each group comprised 46 hip and 27 knee replacement patients and data on predisposing risk factors for prolonged wound exudate were collected. We have calculated the proportion of patients who have exceeded their expected length of stay due to a wound exudate, the additional days required for the wound to dry and the derived cost.

Results:

No significant differences were identified with regards to risk factors. The study group demonstrated a significantly lower incidence of exudating wounds of excessive duration (1% versus 14%, p=0.005, relative risk: 10; 95% confidence interval: 1.31–76.13). The combined additional stay was 22 days more for the control group, producing an average financial benefit of £80 per patient for the study group. There were seven knee replacement and two hip replacement patients treated with a nozzled glue applicator who presented with delayed (> 2 weeks) wound healing issues.

Conclusion:

Barbed subcuticular suture with surface glue application is a viable option for skin closure after elective lower limb joint arthroplasty and can reduce the incidence of prolonged wound discharge. A brushed glue applicator should be preferred over the nozzled one.

Reduced wound leakage in arthroplasty with modified wound closure: a retrospective cohort study

INTRODUCTION

Wound leakage has been shown to increase the risk of prosthetic joint infections (PJIs) in primary total hip (THA) and knee arthroplasty (unicondylar and total knee arthroplasty; KA). The aim of this study is to determine whether the addition of a continuous subcuticular bonding stitch to a conventional three-layer closure method reduces the incidence of prolonged wound leakage and PJIs after THA and KA.

MATERIALS AND METHODS

This retrospective cohort study included all patients receiving a THA or KA. Patients in the control group with a three-layer closure method had surgery between November 1st 2015 and October 31^st 2016, and were compared to the study group with a four-layer closure method that had surgery between January 1st 2017 and December 31^st 2018. The primary outcome was incidence of prolonged wound leakage longer than 72 h. Differences were evaluated using logistic regression. Incidence of PJIs was the secondary outcome.

RESULTS

A total of 439 THA and 339 KA in the control group and 460 THA and 350 KA in the study group were included. In the control group, 11.7% of the patients had a prolonged leaking wound compared to 1.9% in the study group (p < 0.001). The modified wound closure method showed a protective effect for obtaining prolonged wound leakage; odds ratios were 0.09 (95% CI 0.04-0.22; p < 0.001) for THA and 0.21 (95% CI 0.10-0.43; p < 0.001) for KA. PJIs decreased from 1.54 to 0.37% (p = 0.019).

CONCLUSIONS

The addition of a continuous subcuticular bonding stitch reduces the incidence of prolonged wound leakage and PJIs after THA and KA compared to a conventional three-layer wound closure method. The large reduction of incidence in wound leakage and PJIs in this study, combined with relatively negligible cost and effort of the modified wound closure method, would advocate for implementing this wound closure method in arthroplasty.

Does the form of venous thromboembolism prophylaxis following primary total knee arthroplasty alter the rate of early reoperation or revision surgery?

BACKGROUND

Currently there is significant variation in the management of venous thromboembolism prophylaxis following total knee arthroplasty (TKA). Excessive wound ooze and bleeding is thought to increase a patient's risk of haematoma formation and possible infection. We evaluated the rate of unexpected reoperation in the perioperative period in patients who received aspirin, rivaroxaban or enoxaparin following primary TKA.

METHOD

A systematic literature search was conducted in MEDLINE, CENTRAL and Embase to identify patients who underwent primary TKA. Two researchers independently reviewed the references identified in the literature search. The final 11 studies included for review were published between 1996 and 2016.

RESULTS

There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. Of the 5141 patients treated with enoxaparin, 11 (0.21%) required reoperation; of the 2764 patients treated with rivaroxaban, 12 (0.43%) required reoperation; and of the 228 patients treated with aspirin, seven (3.07%) required reoperation. The average time to follow-up in the 11 studies was 55 days, ranging from 30 to 180 days post-operatively.

CONCLUSION

There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. While there is extensive data on the safety and efficacy of these medications following joint arthroplasty, improved reporting of surgically relevant outcomes are needed to assist both the surgeon and patient in clinical decision-making.

Persistent Wound Drainage After Total Joint Arthroplasty: A Narrative Review

BACKGROUND

Persistent wound drainage after total joint arthroplasty (TJA) is an important complication with potential substantial adverse consequences, in particular periprosthetic joint infection.

METHODS

This review evaluated the available literature regarding several issues in the field of persistent wound drainage after TJA and offers a classification of persistent wound drainage and an algorithmic approach to the decision-making process.

RESULTS

Available literature addressing the diagnosis and treatment of persistent wound drainage after TJA is scarce and an evidence-based clinical guideline is lacking. This is partially caused by the absence of a universally accepted definition of persistent wound drainage. In patients with persistent wound drainage, clinical signs and serological tests can be helpful in the diagnosis of a developing infection. Regarding the treatment of persistent wound drainage, nonsurgical treatment consists of absorbent dressings, pressure bandages, and temporary joint immobilization. Surgical treatment is advised when wound drainage persists for more than 5-7 days and consists of open debridement with irrigation and exchange of modular components and antimicrobial treatment.

CONCLUSION

Based on this literature review, we proposed a classification and algorithmic approach for the management of patients with persistent wound drainage after TJA. Hopefully, this offers the orthopedic surgeon a practical clinical guideline by finding the right balance between overtreatment and undertreatment, weighing the risks and benefits. However, this classification and algorithmic approach should first be evaluated in a prospective trial.

Efficacy and safety of limb position on blood loss and range of motion after total knee arthroplasty without tourniquet: A randomized clinical trial

BACKGROUND

The purpose of this study was to investigate the effect of postoperative limb position on blood loss and knee function after primary total knee arthroplasty without tourniquet.

MATERIAL AND METHODS

One hundred patients were randomly assigned into 2 groups: Group A was given a knee flexion position at 60° for 24 h after surgery but without the tourniquet use. Patients in group B was received the tourniquet use the same flexion position as the Group A. All patients received intravenous (IV) tranexamic acid (TXA) 15 mg/kg before skin incision and another 1 g of IV-TXA after 3 h.

RESULTS

The total blood loss was similar in the 2 groups. Group A had significantly less hidden blood loss and drainage volume (P = 0.023, P < 0.001), and higher intraoperative blood loss than the Group B (P < 0.001). The visual analog scale and knee circumference in Group A were lower than the Group B on postoperative days 1, 3 and 5. The range of motion was also lowering in Group A than the Group B on postoperative days 1, 3, 5 and at the 1 month. No significant differences (P > 0.05) were observed between the 2 groups regarding maximum hemoglobin drop, transfusion rate, postoperative hospital stay, DVT and/or PE, and wound-related complications.

CONCLUSION

Based on the current evidence, patients treated with postoperative limb positions without a tourniquet can effectively reduce hidden blood loss and drainage volume, as well as better early clinical benefits than those treated with a tourniquet.

LEVEL OF EVIDENCE

Therapeutic Level I.

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

BACKGROUND

It is a randomized study to compare cement penetration on x-rays after total knee arthroplasty (TKA) among 3 different ways to use tourniquets; application during the surgery, application only with implantation prosthesis and with no tourniquet use.

METHODS

A total 69 knees of 59 patients were included in the study in a quasirandom manner. Each patient had physical exams and standard radiographic evaluations at 6 weeks after the TKA procedure. Outcome evaluations included visual analog scale (VAS) scores, Knee Society Scores (KSS), blood transfusion, and drainage status after surgery for all groups. For radiographic review, the tibial plateau was divided into zones in the anterior-posterior and lateral views, according to the Knee Society Scoring System.

RESULTS

The average age of the patients who were eligible for the study was 65.05 (range 46-81) years. All 59 patients included in the study were female patients. Group 1 consisted of 24 patients who had TKA with use of a tourniquet during the entire operation. Group 2 consisted of 20 patients who had TKA with use of tourniquet only at the time of cementing and group 3 consisted of 25 patients with no use tourniquet. There is no significant difference in early cement penetration among the groups (group 1 2.50 mm, group 2 2.28 mm, group 3 2.27 mm; group 1 vs 2 P = .083, group 1 vs 3 P = .091, group 2 vs 3 P = .073). There is no significant difference for postoperative drainage among the 3 groups (group 1 245 mL, group 2 258.76 mL, group 3 175.88 mL; group 1 vs 2 P = .081, group 1 vs 3 P = .072, group 2 vs 3 P = .054). There was no need to transfuse more than 1 unit in any patient. The VAS score was significantly higher (group 1 3.58, group 2 1.55, group 3 1.52; group 1 vs 2 P = .022, group 1 vs 3 P = .018, group 2 vs 3 P = .062) and KSS was significantly lower in the tourniquet group (group 1 63, group 2 79, group 3 82; group 1 vs 2 P = .017, group 1 vs 3 P = .02, group 2 vs 3 P = .082).

CONCLUSION

We do not suggest long-duration tourniquet use, which can lead higher pain scores and reduce functional recovery after total knee arthroplasty.

Managing persistent wound leakage after total knee and hip arthroplasty. Results of a nationwide survey among Dutch orthopaedic surgeons

Background: Persistent wound leakage after joint arthroplasty is a scantily investigated topic, despite the claimed relation with a higher risk of periprosthetic joint infection. This results in a lack of evidence-based clinical guidelines for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. Without such guideline, clinical practice in orthopaedic hospitals varies widely. In preparation of a nationwide multicenter randomized controlled trial on the optimal treatment of persistent wound leakage, we evaluated current Dutch orthopaedic care for persistent wound leakage after joint arthroplasty. Methods: We conducted a questionnaire-based online survey among all 700 members of the Netherlands Orthopaedic Association, consisting of 23 questions on the definition, classification, diagnosis and treatment of persistent wound leakage after joint arthroplasty. Results: The questionnaire was completed by 127 respondents, representing 68% of the Dutch hospitals that perform orthopaedic surgery. The results showed wide variation in the classification, definition, diagnosis and treatment of persistent wound leakage among Dutch orthopaedic surgeons. 56.7% of the respondents used a protocol for diagnosis and treatment of persistent wound leakage, but only 26.8% utilized the protocol in every patient. Most respondents (59.1%) reported a maximum period of persistent wound leakage before starting non-surgical treatment of 3 to 7 days after index surgery and 44.1% of respondents reported a maximum period of wound leakage of 10 days before converting to surgical treatment. Conclusions: The wide variety in clinical practice underscores the importance of developing an evidence-based clinical guideline for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. To this end, a nationwide multicenter randomized controlled trial will be conducted in the Netherlands, which may provide evidence on this important and poorly understood topic.

The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial

PURPOSE

Tourniquets are still widely used in total knee arthroplasty (TKA), although they may be associated with several adverse effects. An observer-blinded, randomized, controlled trial was performed to evaluate the effects of tourniquet use in TKA.

METHODS

Fifty participants who underwent staged bilateral TKA were recruited for this study. The first-side TKA was randomly allocated to either long-duration tourniquet use or short-duration tourniquet use followed by a 3-month washout period and crossover to the other tourniquet strategy for the opposite-side TKA. Blood loss was monitored perioperatively. The operating time, allogeneic blood transfusion rate, thigh pain, knee pain, limb swelling, clinical outcome as measured by the Likert-type Western Ontario and McMaster University (WOMAC) score, straight leg raising and knee active range of motion (ROM) were also recorded.

RESULTS

The long-duration tourniquet group exhibited reduced total blood loss [-99.1 ml, 95 % confidence interval (CI) -168.1 to -30.1, P = 0.0411] and intraoperative blood loss (-225.2 ml, 95 % CI -369.5 to -80.9, P = 0.0071) compared with the short-duration tourniquet group. However, there were greater postoperative blood loss (69.6 ml, 95 % CI 21.1 to 118.2, P = 0.0282) and hidden blood loss (52.8 ml, 95 % CI 10.5 to 95.1, P = 0.0332) in the long-duration tourniquet group. The short-duration tourniquet group showed better outcomes for thigh and knee pain, limb swelling, WOMAC score at 6-week follow-up, straight leg raising and knee ROM. Similar allogeneic blood transfusion rates were observed for both groups.

CONCLUSION

Total and intraoperative blood losses were reduced with the long-duration tourniquet use, whereas the short-duration tourniquet use would reduce postoperative and hidden blood losses without increasing the allogeneic blood transfusion rate. In addition, short-duration tourniquet use would result in faster recovery and less pain during the early rehabilitation period following TKA.

LEVEL OF EVIDENCE

I.

Effects of Unilateral Tourniquet Used in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty

OBJECTIVE

To assess the benefits of use of a tourniquet in one limb in patients undergoing simultaneous bilateral total knee arthroplasty (TKA).

METHODS

A prospective randomized trial was designed to evaluate the outcomes of unilateral tourniquet use during simultaneous bilateral TKA. A total of 52 (36 women and 16 men) patients with osteoarthritis who underwent simultaneous bilateral primary TKA between January 2010 and January 2015 were assigned randomly to tourniquet (TG) or non-tourniquet (NG) groups prior to surgery. Operating time, pain score, range of motion, first active straight-leg raise time, swelling, wound healing, deep vein thrombosis, and Knee Society score were observed.

RESULTS

Mean operating time in the TG group was shorter than that in the NG group (P < 0.05). Postoperative pain was measured by a visual analog scale (VAS) and straight-leg raise time, which was lower and shorter in limbs operated without the use of a tourniquet (P < 0.05). In addition, this group had less postoperative swelling and lower incidence of wound complications in the early postoperative period (P < 0.05). There was no significant difference in the range of motion (ROM), deep venous thrombosis incidence, and Knee Society scores between the two groups.

CONCLUSIONS

Tourniquet use in bilateral TKA can reduce intraoperative time but was associated with a higher incidence of wound complications and larger postoperative knee swelling.

Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

BACKGROUND

Tourniquet use during total knee arthroplasty (TKA) improves visibility and reduces intraoperative blood loss. However, tourniquet use may also have a negative impact on early recovery of muscle strength and lower extremity function after TKA.

QUESTIONS/PURPOSES

The purpose of this study was (1) to determine whether tourniquet use affects recovery of quadriceps strength (primary outcome) during the first 3 postoperative months; and (2) to examine the effects of tourniquet application on secondary outcomes: voluntary quadriceps activation, hamstring strength, unilateral limb balance as well as the effect on operative time and blood loss.

METHODS

Twenty-eight patients (mean age 62 ± 6 years; 16 men) undergoing same-day bilateral TKA (56 lower extremities) were enrolled in a prospective, randomized study. Subjects were randomized to receive a tourniquet-assisted knee arthroplasty on one lower extremity while the contralateral limb underwent knee arthroplasty without extended tourniquet use. In the former group, the tourniquet was inflated just before the incision was made and released after cementation; in the latter group, a tourniquet was not used (10 of 28 [36%]) or inflated only during component cementation (18 of 28 [64%]). The choice of no tourniquet or use just during cementation was based on surgeon choice, because some surgeons felt a tourniquet during cementation was necessary to achieve a dry surgical field to maximize cement fixation. A median parapatellar approach and the identical posterior-stabilized TKA design were used by all four fellowship-trained knee surgeons involved. Isometric quadriceps strength, hamstring strength, voluntary quadriceps activation, and unilateral balance were assessed preoperatively, 3 weeks, and 3 months after bilateral knee arthroplasty. Other factors, including pain, range of motion, and lower extremity girth, were assessed for descriptive purposes at each of these time points as well as on the second postoperative day.

RESULTS

Quadriceps strength was slightly lower in the tourniquet group compared with the no-tourniquet group (group difference = 11.27 Nm [95% confidence interval {CI}, 2.33-20.20]; p = 0.01), and these differences persisted at 3 months after surgery (group difference = 9.48 Nm [95% CI, 0.43-18.54]; p = 0.03). Hamstring strength did not differ between groups at any time point nor did measures of quadriceps voluntary activation or measures of unilateral balance ability. There was less estimated intraoperative blood loss in the tourniquet group (84 ± 26 mL) than in the no-tourniquet group (156 ± 63 mL) (group difference = -74 mL [95% CI, -100 to -49]; p < 0.001). However, there was no difference in total blood loss between the groups (group difference = -136 mL [95% CI, -318 to 45]; p = 0.13).

CONCLUSIONS

Patients who underwent TKA using a tourniquet had diminished quadriceps strength during the first 3 months after TKA, the clinical significance of which is unclear. Future studies may be warranted to examine the effects of tourniquet use on long-term strength and functional outcomes.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Benefits of Limited Use of a Tourniquet Combined With Intravenous Tranexamic Acid During Total Knee Arthroplasty

BACKGROUND

Blood loss during total knee arthroplasty (TKA) may require blood transfusions that are associated with increased risk, morbidity, and cost. Multiple techniques exist to reduce blood loss in TKA, including the use of a tourniquet and tranexamic acid (TXA). While multiple studies suggest that TXA is effective in reducing blood loss, the use of a tourniquet is more controversial. We studied the combined effect of TXA with a limited-use tourniquet on blood loss and complications in the setting of primary TKA.

METHODS

A retrospective review of a prospectively gathered arthroplasty database from a single institution was performed. We compared our limited-use cohort data with the published results of randomized controlled trials evaluating the effectiveness of tourniquets used during the entire TKA procedure.

RESULTS

Fifty-one procedures from our institution's database met the inclusion criteria. TXA (administered in a single 15-mg/kg dose) with limited tourniquet use (a mean duration of 26.3 minutes) resulted in an average intraoperative estimated blood loss of 94.7 mL. The mean decrease in hemoglobin from the preprocedure baseline to postoperative day 1 was 2.6 ± 0.9 g/dL (P<0.001), and only 2 of the 51 procedures required a blood transfusion. When compared to recent randomized controlled trials, the 51 procedures demonstrated lower levels of blood loss, similar operative time, and no increase in morbidity or mortality.

CONCLUSION

Our study results suggest that using TXA in combination with a tourniquet during the cementation portion only of a TKA provides a reasonable operative time and low intraoperative blood loss without increasing perioperative morbidity or complications.

The constraints on day-case total knee arthroplasty: the fastest fast track

Total knee arthroplasty (TKA) is a major orthopaedic intervention. The length of a patient's stay has been progressively reduced with the introduction of enhanced recovery protocols: day-case surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case TKA. These constraints may be social, linked to patient's comorbidities, or due to surgery-related adverse events (e.g. pain, post-operative nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and multimodal opioid-sparing analgesia, day-case TKA might be achievable in a limited group of patients. The younger, male patient without comorbidities and with an excellent social network around him might be a candidate. Demographic changes, effective recovery programmes and less invasive surgical techniques such as unicondylar knee arthroplasty, may increase the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced against any increase in morbidity and mortality and the cost of advanced follow-up at a distance with new technology. These factors need to be evaluated before adopting this ultimate 'fast-track' approach.

Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The aim of this study is to evaluate the effects of tourniquet release before wound closure for hemostasis or after wound closure in cemented total knee arthroplasty (TKA).

METHODS

We conducted a meta-analysis and review work on relevant clinical outcomes to evaluate the effects of the timing of tourniquet release in cemented TKA. Electronic databases were searched for relevant randomized controlled trials (RCTs) that compared outcomes of tourniquet release before wound closure for hemostasis with tourniquet release after wound closure. The methodological quality of each included RCT was assessed in terms of the 12-item scale. The meta-analysis was performed with STATA 12.0 software.

RESULTS

Eleven RCTs involving 651 patients with 670 TKAs were included in this meta-analysis. Of these, 332 patients (342 knees) were in an early tourniquet release group and 319 patients (328 knees) in the late tourniquet release group. The results showed that there were no significant differences in overt blood loss, hemoglobin drop, and blood transfusions, whereas the tourniquet release after wound closure might increase the risks of overall complications and major complications.

CONCLUSIONS

Tourniquet release before wound closure for hemostasis might reduce the rate of complications, but it could not limit overall blood loss. The current evidences are not enough to indicate that tourniquet release before wound closure is superior to its release after wound closure in cemented TKA.

Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty

Purpose

A pneumatic tourniquet is commonly used in total knee arthroplasty (TKA) to improve surgical field visualisation but may result in quadriceps muscle ischaemia. We performed this study to analyse the effect of the tourniquet on recovery following TKA.

Materials and Methods

A prospective randomised single-blinded trial was undertaken to examine the effect of the tourniquet on post-operative pain, swelling, blood loss, quadriceps function and outcome following TKA. Twenty patients with osteoarthritis of the knee were randomised to tourniquet or no tourniquet groups. Quadriceps function was assessed using surface electromyography (EMG) during active knee extension.

Results

The no tourniquet group had significantly less pain in the early post-operative period compared to the tourniquet group. There was no difference in Oxford knee score, range of motion, or thigh and knee swelling up to 12 months post-operatively. Quadriceps function, measured by surface EMG, was compromised for the first six months post-surgery by tourniquet use. The radiological cement mantle at the bone prosthesis interface at 12-month follow-up was not affected by the absence of a tourniquet.

Conclusions

We believe that it is safe and beneficial for our patients to routinely perform TKA without a tourniquet.

The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis

BACKGROUND

Pneumatic tourniquet use in total knee arthroplasty (TKA) is always a controversial issue. The aim of the present study is to assess the effectiveness and safety of its use in patients receiving primary unilateral TKA, and to explore the most safe and effective protocols.

MATERIALS AND METHODS

This review was based on cochrane methodology for conducting meta-analysis. Only randomized controlled trials (RCTs) were eligible for this study. The participants were adults who had undergone primary unilateral TKA. The Review Manager Database (RevMan version 5.0, The Cochrane Collaboration 2008) was used to analyze the dates of the selected studies.

RESULTS

Thirteen RCTs involving 859 patients were included in this analysis. The use of tourniquet could significantly reduce operation time (mean difference -5.01 min, P = 0.003), intraoperative blood loss (mean difference -201.85 ml, P < 0.00001) and total blood loss volumes (mean difference -125.03 ml, P = 0.61). But postoperative (mean difference 45.99 ml, P = 0.68) were slightly increased in that situation. With respect to surgical complications, a tendency of increasing risk ratio was observed for tourniquet group.

CONCLUSIONS

Our results indicate that tourniquet application could reduce surgical time, intraoperative blood loss and total blood loss, but increases postoperative total blood loss. With respect to postoperative complications, DVT and surgical site infection rates are relatively augmented in the tourniquet group.

The effects of a tourniquet used in total knee arthroplasty: a meta-analysis

Background

The purpose of this research is to evaluate the effects of a tourniquet in total knee arthroplasty (TKA).

Methods

The study was done by randomized controlled trials (RCTs) on the effects of a tourniquet in TKA. All related articles which were published up to June 2013 from Medline, Embase, and Cochrane Central Register of Controlled Trails were identified. The methodological quality of the included studies was assessed by the Physiotherapy Evidence Database (PEDro) scale. The meta-analysis was performed using Cochrane RevMan software version 5.1.

Results

Thirteen RCTs that involved a total of 689 patients with 689 knees were included in the meta-analysis, which were divided into two groups. The tourniquet group included 351 knees and the non-tourniquet group included 338 knees. The meta-analysis showed that using a tourniquet in TKA could reduce intraoperative blood loss (weighted mean difference (WMD), -198.21; 95% confidence interval (CI), -279.82 to -116.60; P < 0.01) but did not decrease the calculated blood loss (P = 0.80), which indicates the actual blood loss. Although TKA with a tourniquet could save the operation time for 4.57 min compared to TKA without a tourniquet (WMD, -4.57; 95% CI, -7.59 to -1.56; P < 0.01), it had no clinical significance. Meanwhile, the use of tourniquet could not reduce the possibility of blood transfusion (P > 0.05). Postoperative knee range of motion (ROM) in tourniquet group was 10.41° less than that in the non-tourniquet group in early stage (≤10 days after surgery) (WMD, -10.41; 95% CI, -16.41 to -4.41; P < 0.01). Moreover, the use of a tourniquet increased the risk of either thrombotic events (risk ratio (RR), 5.00; 95% CI, 1.31 to 19.10; P = 0.02) or non-thrombotic complications (RR, 2.03; 95% CI, 1.12 to 3.67; P = 0.02).

Conclusions

TKA without a tourniquet was superior to TKA with a tourniquet in thromboembolic events and the other related complications. There were no significant differences between the two groups in the actual blood loss. TKA with a tourniquet might hinder patients' early postoperative rehabilitation exercises.

An evidence-based review of enhanced recovery interventions in knee replacement surgery

INTRODUCTION

Total knee replacement (TKR) is a very common surgical procedure. Improved pain management techniques, surgical practices and the introduction of novel interventions have enhanced the patient's postoperative experience after TKR. Safe, efficient pathways are needed to address the increasing need for knee arthroplasty in the UK. Enhanced recovery programmes can help to reduce hospital stays following knee replacements while maintaining patient safety and satisfaction. This review outlines common evidence-based pre, intra and postoperative interventions in use in enhanced recovery protocols following TKR.

METHODS

A thorough literature search of the electronic healthcare databases (MEDLINE(®), Embase™ and the Cochrane Library) was conducted to identify articles and studies concerned with enhanced recovery and fast track pathways for TKR.

RESULTS

A literature review revealed several non-operative and operative interventions that are effective in enhanced recovery following TKR including preoperative patient education, pre-emptive and local infiltration analgesia, preoperative nutrition, neuromuscular electrical stimulation, pulsed electromagnetic fields, perioperative rehabilitation, modern wound dressings, different standard surgical techniques, minimally invasive surgery and computer assisted surgery.

CONCLUSIONS

Enhanced recovery programmes require a multidisciplinary team of dedicated professionals, principally involving preoperative education, multimodal pain control and accelerated rehabilitation; this will be boosted if combined with minimally invasive surgery. The current economic climate and restricted healthcare budget further necessitate brief hospitalisation while minimising costs. These non-operative interventions are the way forward to achieve such requirements.

Tourniquet time affects postoperative complications after knee arthroplasty

PURPOSE

Pneumatic tourniquets are frequently used in knee arthroplasty surgery. However, there is a lack of evidence to define safe tourniquet time in lower limb surgery. The primary aim of this study was to investigate whether tourniquet time influences the risk of postoperative complications after primary and secondary knee arthroplasty.

METHODS

This study was a prospective register study. Since we wanted dispersion in tourniquet time, we included a consecutive series of 577 primary knee arthroplasties, 46 revision knee arthroplasties, and 18 patellar supplementing knee arthroplasties from a clinical audit database over a period of five years. The following postoperative complications were recorded: superficial wound infections, deep wound infections, deep vein thrombosis, pulmonary embolism, nerve injuries, compartment syndrome, cuff pressure injuries, and bandage injuries.

RESULTS

Tourniquet time over 100 minutes was associated with an increased risk of complications after knee arthroplasty surgery (OR 2.2, CI 1.5-3.1). This increase in risk remained after adjusting for cuff pressure, sex, age, American Society of Anesthesiologists (ASA) classification, smoking, diabetes, and surgery indication (OR 2.4, CI 1.6-3.6).

CONCLUSIONS

Tourniquet time over 100 minutes increases the risk of complications after knee arthroplasty surgery and special attention is advocated to reduce the tourniquet time.