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Ghazni Khan MA, Sulaiman MA, Zahid M, Kumar S, Ahmad T. Role of tourniquet release timing on blood loss and functional outcomes in total knee arthroplasty: Insights from a low- and middle-income country. J Exp Orthop 2024; 11:e12075. [PMID: 39050594 PMCID: PMC11267165 DOI: 10.1002/jeo2.12075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 05/29/2024] [Accepted: 06/17/2024] [Indexed: 07/27/2024] Open
Abstract
Purpose To identify the effect of releasing a tourniquet before versus after wound closure in total knee arthroplasty (TKA) on blood loss, functional outcome and postoperative complications. Methodology A prospective cohort study was conducted including 53 patients from May 2023 to September 2023. All patients underwent unilateral TKA and were divided into two groups based on surgeon preference of deflating tourniquet, Group A consisted of patients in whom the tourniquet was deflated before wound closure for haemostasis and Group B consisted of patients in which tourniquet was deflated after wound closure and compressive dressing. Blood loss was evaluated via intraoperative blood loss (the number of soaked sponges/gauzes, blood in a suction bottle, total output in a suction bottle-irrigation used) and on-field blood loss and calculated blood loss (Using Gross and Meunier's formula). The Functional outcome was evaluated using Knee injury and osteoarthritis score-42 questions. Early postoperative complications and differences in the requirement of blood transfusions were also assessed. Results There was a significant difference in intraoperative blood loss between the two groups. The median intraoperative blood loss was 135 mL (interquartile range [IQR]: 90-149) in Group A and 56.2 mL (IQR: 45-68) in Group B (p value: 0.001). However, no difference was found between the groups in calculated blood loss using Gross and Meunier's formula. The median calculated blood loss was 439 mL (IQR: 450-813) in Group A and 508 mL (IQR: 226-671) in group B (p value: 0.981). There was no significant difference between the groups in blood transfusion requirements or functional outcomes. Conclusion Based on our results, we conclude that the intraoperative blood loss in TKA is significantly different between the groups but only represents a fraction of true blood loss (23%). The timing of releasing the tourniquet does not affect functional outcomes, blood transfusion and postoperative morbidity; hence, any time can be opted as per surgeon preference. Level of Evidence Level II, prospective comparative study.
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Affiliation(s)
| | | | - Marij Zahid
- Department of SurgeryAga Khan University HospitalKarachiPakistan
| | - Suresh Kumar
- Department of SurgeryAga Khan University HospitalKarachiPakistan
| | - Tashfeen Ahmad
- Department of SurgeryAga Khan University HospitalKarachiPakistan
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2
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Edgar M, Harvey J, Jiang S, Walters J, Kozina E, Kaplan N, Redondo M, Zabawa L, Chmell S. Cemented total knee arthroplasty provides greater knee range of motion at 2 years than cementless technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3561-3568. [PMID: 37231309 DOI: 10.1007/s00590-023-03596-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Optimal fixation method between cemented, cementless, and hybrid techniques for total knee arthroplasty (TKA) is still debated. The purpose of this study is to evaluate the clinical outcomes of patients undergoing cemented versus cementless TKA. METHODS We reviewed 168 patients who underwent a primary TKA at a single academic institution between January 2015 and June 2017. Patients were categorized into cemented (n = 80) or cementless (n = 88) groups. Only patients with greater than or equal to 2-year follow-up were included in the study. Multivariate regressions were performed to analyze the relationship between the surgical fixation technique and the clinical outcomes. RESULTS There were no differences in demographics or baseline operative characteristics between the two groups. The cemented group had fewer manipulations under anesthesia (MUA) (4 vs. 15, p = 0.01), longer intraoperative tourniquet times (101.30 vs. 93.55 min, p = 0.02), and increased knee range of motion (ROM) at final follow-up (111.48 vs. 103.75°, p = 0.02) compared to the cementless group. DISCUSSION AND CONCLUSION Both cemented and cementless component fixation are viable options for (TKA). This study found that patients who underwent a cemented TKA required fewer MUA's and had greater final ROM compared to patients undergoing cementless TKA. Additional research is required regarding cementless and cemented fixation. We believe that the choice of which fixation technique to use ultimately comes down to patient characteristics and surgeon preference.
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Affiliation(s)
- Michael Edgar
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA.
| | - Jack Harvey
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Sam Jiang
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Jhunelle Walters
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Erik Kozina
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Nicholas Kaplan
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Michael Redondo
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Luke Zabawa
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Samuel Chmell
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
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3
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Kozai L, Matsumoto M, Mathews K, Andrews S, Nakasone C. Perioperative Complications in Patients over 70 Years of Age following Simultaneous Bilateral Total Knee Arthroplasty. J Knee Surg 2023; 36:362-367. [PMID: 34348399 DOI: 10.1055/s-0041-1733884] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Single-stage bilateral total knee arthroplasty (ssBTKA) can be used for patients presenting with bilateral arthritis and may result in fewer systemic and wound complications compared with two, independent procedures. However, the safety of ssBTKA in the elderly remains controversial. Therefore, the purpose of this study was to compare early complications and transfusion rates following ssBTKA in patients ≤ 70 years old or > 70 years old. This retrospective chart review of 313 consecutive patients undergoing ssBTKA included 174 patients ≤ 70 years old and 139 patients > 70 years old. Perioperative variables and postoperative complications were compared with univariate analyses between age groups. Multivariate analyses were performed to determine risk factors for developing perioperative complications and transfusions. Compared with patients ≤ 70, patients > 70 had significantly lower body mass index (p < 0.001) and were more commonly female (p = 0.024). Although wound (p > 0.12) and systemic complications (p > 0.54) were similar, 23% of patients > 70 required transfusion compared with only 8% of patients ≤ 70 (p < 0.001). Patients with preoperative anemia (p < 0.001), age > 70 (p = 0.002), or diabetes mellitus (p = 0.007) were at 5.7, 3.3, and 2.9 times greater risk for requiring a transfusion, respectively. Patients > 70 undergoing ssBTKA have a similar complication profile to patients ≤ 70 years old, suggesting age should not be an absolute exclusion criterion for ssBTKA. However, the risk of transfusion was significantly higher in those > 70, despite lower tourniquet times. Treatment of preoperative anemia may decrease the risk of transfusion and could provide adequate safety for patients > 70 to undergo ssBTKA by an experienced surgeon.
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Affiliation(s)
- Landon Kozai
- John A. Burns School of Medicine, Honolulu, Hawaii
| | - Maya Matsumoto
- John A. Burns School of Medicine, Honolulu, Hawaii.,Straub Medical Center, Bone and Joint Center, Honolulu, Hawaii
| | - Kristin Mathews
- Straub Medical Center, Bone and Joint Center, Honolulu, Hawaii
| | - Samantha Andrews
- Straub Medical Center, Bone and Joint Center, Honolulu, Hawaii.,Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Cass Nakasone
- Straub Medical Center, Bone and Joint Center, Honolulu, Hawaii.,Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
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Ishii M, Wong K, Shimoda B, Andrews S, Au D, Nakasone CK. Do older patients fare worse following unilateral or single stage bilateral total knee arthroplasty? Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04749-y. [PMID: 36604320 PMCID: PMC9815680 DOI: 10.1007/s00402-022-04749-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/29/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The safety and benefits of single stage bilateral total knee arthroplasty (SSBTKA) among older patients as compared to unilateral TKA remains controversial. This study aimed to evaluate the influence of age and comorbidities on complications and early outcomes for unilateral and BTKA in patients over and under 70 years of age. MATERIALS AND METHODS This prospective study compared postoperative complications and early patient-reported outcomes at 6 weeks of 142 unilateral TKA patients (N = 75, ≤ 70; N = 67, > 70) and 89 SSBTKA patients (N = 48, ≤ 70; N = 41, > 70). Patients completed the KOOS JR and PROMIS Global Mental (GMH) and Global Physical Health (GPH) surveys. Knee Society Scores for Knee (KSS-K) and Function (KSS-F) were completed in the clinic. Parametric tests were performed for comparisons of unilateral and BTKA outcomes and complications for patients over and under 70. RESULTS While patient demographics were similar, patients > 70 had more comorbidities than patients ≤ 70 (p < 0.004). There were no significant differences in postoperative complications or readmissions between age groups or procedures. Unilateral TKA patients > 70 had significantly lower pre- (p < 0.001) and post-operative (p = 0.011) KSS-F scores compared to those ≤ 70. SSBTKA patients > 70 had significantly higher preoperative GMH (p = 0.029), postoperative KSS-K (p = 0.027), KOOS JR scores (p = 0.039) and satisfaction (p = 0.048) compared to those ≤ 70. CONCLUSION Age did not influence the risk of early postoperative complications. Additionally, the greater improvements in KOOS JR and higher patient satisfaction for SSBTKA patients > 70 suggests that SSBTKA may meet elderly patient expectations and should not necessarily be discouraged due to safety concerns.
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Affiliation(s)
- Megan Ishii
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Krystin Wong
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Brent Shimoda
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96813, USA
| | - Samantha Andrews
- Department of Surgery, University of Hawai'i, 1356 Lusitana Street, Honolulu, HI, 96813, USA
| | - Donna Au
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96813, USA
| | - Cass K Nakasone
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96813, USA.
- Department of Surgery, University of Hawai'i, 1356 Lusitana Street, Honolulu, HI, 96813, USA.
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5
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Cao Q, Wu Q, Liu Y, He Z, Cong Y, Meng J, Zhao J, Bao N. 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. J Knee Surg 2022; 35:1577-1586. [PMID: 33992032 DOI: 10.1055/s-0041-1728814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Qinggang Cao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Qiong Wu
- Department of Scientific Research and Training, Division of Health Service, General Hospital of Eastern theater of People's Liberation Army, Nanjing, Jiangsu, China
| | - Yun Liu
- Health Technology Cadre Training, Jingling Hospital, Nanjing, China
| | - Zhiwei He
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Yu Cong
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jia Meng
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jianning Zhao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China.,Health Technology Cadre Training, Jingling Hospital, Nanjing, China
| | - Nirong Bao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China.,Health Technology Cadre Training, Jingling Hospital, Nanjing, China
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6
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Frenkel Rutenberg T, Vitenberg M, Daglan E, Kadar A, Shemesh S. Single Surgeon versus Co-Surgeons in Primary Total Joint Arthroplasty: Does "Two Is Better than One" Apply to Surgeons? J Pers Med 2022; 12:jpm12101683. [PMID: 36294821 PMCID: PMC9604737 DOI: 10.3390/jpm12101683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 09/26/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND As the demand for total joint arthroplasties (TJA) increases steadily, so does the pressure to train future surgeons and, at the same time, achieve optimal outcomes. We aimed to identify differences in operative times and short-term surgical outcomes of TJAs performed by co-surgeons versus a single attending surgeon. METHODS A retrospective analysis of 597 TJAs, including 239 total hip arthroplasties (THAs) and 358 total knee arthroplasties (TKAs) was conducted. All operations were performed by one of four fellowship-trained attending surgeons as the primary surgeon. The assisting surgeons were either attendings or residents. RESULTS In 51% of THA and in 38% of TKA, two attending surgeons were scrubbed in. An additional scrubbed-in attending was not found to be beneficial in terms of surgical time reduction or need for revision surgeries within the postoperative year. This was also true for THAs and for TKAs separately. An attending co-surgeon was associated with a longer hospital stay (p = 0.028). Surgeries performed by fewer surgeons were associated with a shorter surgical time (p = 0.036) and an increased need for blood transfusion (p = 0.033). Neither the rate of intraoperative complications nor revisions differed between groups, regardless of the number of attending surgeons scrubbed in or the total number of surgeons. CONCLUSION A surgical team comprised of more than a single attending surgeon in TJAs was not found to reduce surgical time, while the participation of residents was not related with worse patient outcomes.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Maria Vitenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Efrat Daglan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Assaf Kadar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Shai Shemesh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
- Correspondence:
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7
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Sah AP. Clinical Outcomes and Experience of a Multiyear Consecutive Case Series of Total Knee Arthroplasty Procedures Conducted with a Bipolar Sealer System for Hemostasis. J Knee Surg 2022; 35:1378-1384. [PMID: 33607677 DOI: 10.1055/s-0041-1723972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Maximizing hemostasis during total knee replacement procedures remains a key challenge in current practice. Bipolar sealer technology achieves intraoperative hemostasis through tissue sealing and coagulation with adjustable radio frequency energy and a saline-irrigated tip. Optimal surgical site hemostasis is important to avoid potential complications such as hemarthrosis, wound drainage, increased pain, delayed discharge, and readmissions. The aim of this study is to evaluate the safety and effectiveness of the bipolar sealer device in primary knee replacement in the largest consecutive series to date. A consecutive, treatment-control series of subjects who underwent a primary total knee arthroplasty (TKA) utilizing a bipolar sealer for hemostasis, one subgroup with concomitant tranexamic acid (TXA) administration (n = 1599) and one subgroup without TXA administration (n = 3582), compared with a control group of primary TKA under tourniquet only (n = 667). Statistical analyses were performed through two-tailed unpaired t-tests. There was less total postoperative drain output and a lower overall transfusion rate in the bipolar sealer group (807ml ± 428) (2.5%) than the tourniquet only group (1290 ± 658, p = 0.001) (8.4%, p = 0.0001), respectively. Drainage output in bipolar sealer + TXA (450 ± 297 ml) was lower than the other two groups (bipolar sealer 807 ± 428 mL, p = 0.0001; tourniquet only 1290 ± 658 ml, p = 0.0001). The bipolar sealer group had a higher hematocrit at postoperative day 1 (POD1) (bipolar sealer: 33.1 ± 4.3 cc, tourniquet only: 32.5 ± 4.3 cc, p = 0.001) and at discharge (POD2, bipolar sealer: 31.5 ± 3.7 cc, tourniquet only: 30.2 ± 3.9 cc, p = 0.0001). There were zero reported serious adverse events related to hemostasis management in any group. The bipolar sealer system is a safe and effective instrument to achieve intraoperative hemostasis during primary TKA. The bipolar sealer group required significantly fewer postoperative blood product transfusions and maintained a higher hematocrit concentration at the time of discharge compared with subjects treated solely with tourniquet mediated hemostasis. Addition of TXA to local hemostasis methods may further reduce blood loss and transfusion requirements. LEVEL OF EVIDENCE: This is a Level III study.
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Affiliation(s)
- Alexander P Sah
- Sah Orthopaedic Associates, Institute for Joint Restoration, Center for Joint Replacement Bldg, Fremont, California
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8
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Motesharei A, Batailler C, De Massari D, Vincent G, Chen AF, Lustig S. Predicting robotic-assisted total knee arthroplasty operating time. Bone Jt Open 2022; 3:383-389. [PMID: 35532348 PMCID: PMC9134836 DOI: 10.1302/2633-1462.35.bjo-2022-0014.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims No predictive model has been published to forecast operating time for total knee arthroplasty (TKA). The aims of this study were to design and validate a predictive model to estimate operating time for robotic-assisted TKA based on demographic data, and evaluate the added predictive power of CT scan-based predictors and their impact on the accuracy of the predictive model. Methods A retrospective study was conducted on 1,061 TKAs performed from January 2016 to December 2019 with an image-based robotic-assisted system. Demographic data included age, sex, height, and weight. The femoral and tibial mechanical axis and the osteophyte volume were calculated from CT scans. These inputs were used to develop a predictive model aimed to predict operating time based on demographic data only, and demographic and 3D patient anatomy data. Results The key factors for predicting operating time were the surgeon and patient weight, followed by 12 anatomical parameters derived from CT scans. The predictive model based only on demographic data showed that 90% of predictions were within 15 minutes of actual operating time, with 73% within ten minutes. The predictive model including demographic data and CT scans showed that 94% of predictions were within 15 minutes of actual operating time and 88% within ten minutes. Conclusion The primary factors for predicting robotic-assisted TKA operating time were surgeon, patient weight, and osteophyte volume. This study demonstrates that incorporating 3D patient-specific data can improve operating time predictions models, which may lead to improved operating room planning and efficiency. Cite this article: Bone Jt Open 2022;3(5):383–389.
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Affiliation(s)
| | - Cecile Batailler
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
| | | | | | - Antonia F. Chen
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | - Sébastien Lustig
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
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Tang A, Zak SG, Waren D, Iorio R, Slover JD, Bosco JA, Schwarzkopf R. Low-Dose Aspirin is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Knee Arthroplasty: A Retrospective Cohort Study. J Knee Surg 2022; 35:553-559. [PMID: 32898907 DOI: 10.1055/s-0040-1716377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE; p = 0.27), DVT (p = 0.35), and total VTE rates (p = 0.16) among patients using either protocol. There were also no differences in bleeding complications (p = 0.15) or infection rate (p = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Stephen G Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Daniel Waren
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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10
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Sato H, Chikuda J, Saito Y, Katsuta H, Yano T, Shimane T. A case of carcinoma of the lower gingiva with thrombosis in the flap at the collection of the vascularized fibular flap and postoperative subendocardial infarction. ORAL AND MAXILLOFACIAL SURGERY CASES 2022. [DOI: 10.1016/j.omsc.2022.100245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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11
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Li S, Zhang X, Liu M, Lu Q, Yu Y, Miao Z, Luo D, Han K, Li L, Qian W, Liu P. Not using a tourniquet is superior to tourniquet use for high tibial osteotomy: a prospective, randomised controlled trial. INTERNATIONAL ORTHOPAEDICS 2021; 46:823-829. [PMID: 34677629 DOI: 10.1007/s00264-021-05246-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Tourniquets are routinely used in high tibial osteotomy (HTO). However, research on the necessity of tourniquets during HTO is lacking. This study was designed to investigate the necessity of tourniquets in HTO. METHODS This was a prospective study that included patients who underwent HTO at the same hospital. The patients were randomised into Group A (non-tourniquet, n = 45) and Group B (tourniquet, n = 45). Same surgical techniques and haemostatic methods were used in the two groups. RESULTS All patients were followed up for more than three months. There was no difference in operation time, and no intra-operative vascular or nerve damage occurred in either group. The hospital stay was shorter in group A than in group B (p < 0.05). There was no difference in post-operative blood loss, haemoglobin or haematocrit (p > 0.05). The post-operative visual analogue scale (VAS) pain scores and calf swelling were lower in group A (p < 0.05), and the early knee range of motion was higher in group A (p < 0.05). The use of morphine and the incidence of thigh complications were also lower in group A (p < 0.05). There was no difference in the VAS and knee function between the two groups at three months post-operatively (p > 0.05). CONCLUSION Tourniquet use during HTO does not reduce post-operative blood loss, operation time or intra-operative complications, but not using a tourniquet shortens the hospital stay and reduces the post-operative usage of morphine and tourniquet-related complications, which promotes early recovery of knee function.
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Affiliation(s)
- Songlin Li
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China.,Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xiangshuai Zhang
- Department of Orthopedics, Shenxian Central Hospital of Shandong Province, Liaocheng, Shandong, China
| | - Mingxing Liu
- Department of Orthopedics, Zibo Boshan District Hospital of Traditional Chinese Medicine, Zibo, Shandong, China
| | - Qunshan Lu
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yang Yu
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Zhuang Miao
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Desu Luo
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Kaifei Han
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Lei Li
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Wenwei Qian
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Peilai Liu
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.
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Netaji J, Banerjee S, Garg PK, Elhence A. Reappraisal of Limited Duration Tourniquet in Total Knee Arthroplasty: A Double-Blinded RCT. Indian J Orthop 2021; 55:1186-1194. [PMID: 34824719 PMCID: PMC8586269 DOI: 10.1007/s43465-021-00506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/01/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The majority of arthroplasty surgeons use a full duration of tourniquet while doing total knee arthroplasty. Recent literature suggests clinical dilemma about superior function with limited duration use of a tourniquet. The purpose of this study is to evaluate the time-dependent effects and clinical outcome of tourniquet in patients undergoing total knee arthroplasty (TKA) and to assess the incidence of adverse vascular events of the limb in TKA. This study is the first of its kind to evaluate all the serious vascular events prospectively. METHODS Sixty participants who underwent TKA in the duration of 1.5 years at a large single tertiary care centre were recruited and randomly allocated in two groups: Full duration tourniquet (n = 30) and tourniquet only during cementation (n = 30). All patients underwent preoperative and postoperative arterial and venous Doppler to evaluate the presence of thrombosis. The operative duration, blood loss, and clinical outcome (visual analogue scale, active knee range of motion, Knee Society score, and duration of stay) were recorded. RESULTS The incidence of vascular complications was not statistically significant in either group (P = 0.99). Tourniquet during cementation only group exhibited decreased postoperative pain on days 1, 2, and 3 (P < 0.01). But postoperative knee active range of motion was the same between the two groups with no significant postoperative complications. CONCLUSION Tourniquet use only during cementation could result in faster recovery and less pain during the early rehabilitation period with no influence over the incidence of serious vascular events. TRIAL REGISTRY NUMBER AIIMS/IEC/2018/475. This study was approved by the Research Ethics Committee at All India Institute of Medical Sciences, Jodhpur and was carried out at AIIMS (Jodhpur), India.
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Affiliation(s)
- Jeshwanth Netaji
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, 342005 Rajasthan India
| | - Sumit Banerjee
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, 342005 Rajasthan India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Abhay Elhence
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, 342005 Rajasthan India
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13
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Risk of Revision and Adverse Outcomes Following Partial Knee Replacement and High Tibial Osteotomy for Unicompartmental Knee Osteoarthritis: A Nationwide Cohort Study. Indian J Orthop 2021; 55:1101-1110. [PMID: 34824709 PMCID: PMC8586119 DOI: 10.1007/s43465-021-00517-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/05/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To investigate comparative study for potential associations of adverse outcomes as well as survival rates after high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA). METHODS We reviewed the Korean National Health Insurance claims database from January 1, 2007 to May 31, 2019. A total of 90,705 patients aged 30-90 years who were newly treated for HTO or UKA were identified considering their eligibility. We performed four rounds of propensity score matching to reduce imbalance of baseline characteristics, especially disparities among different age groups. Multivariable logistic regression models were used to compare the risk of revision and various unwanted medical problems between HTO and UKA treatment groups after propensity score matching. RESULTS 23,563 matched patients were assigned to each group on the basis of propensity score. HTO showed higher risk of revision than UKA at 5 years, 10 years and the whole observed period (hazard ratio: 1.21, 95% CI 1.10-1.34). Deep vein thromboembolism (0.27, 0.21-0.35), and surgical site infection (0.37, 0.30-0.44) were less likely for HTOs than UKAs. Postoperative admission to intensive care unit was significantly lower with HTO (odds ratio: 0.40, 0.29-0.54) while rehospitalization within 30 days (1.27, 1.16-1.38) and 90 days (1.24, 1.18-1.30) were higher than UKA. CONCLUSION When choosing the surgical method for unicompartmental knee OA, not only the survival rate, but also the risk of other adverse outcomes should be considered. In particular, attention should be paid to the risk of developing deep vein thromboembolism and surgical site infection. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00517-z.
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14
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Aspirin Use for Venous Thromboembolism Prevention Is Safe and Effective in Overweight and Obese Patients Undergoing Revision Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:S337-S344. [PMID: 33376036 DOI: 10.1016/j.arth.2020.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/29/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), defined as pulmonary embolism or deep venous thrombosis, is a rare but serious complication following revision total hip arthroplasty (RTHA) and revision total knee arthroplasty (RTKA). Previous studies show that obesity may be associated with an increased risk for pulmonary embolism, wound complications, and infection. With no current universal standard of care for VTE prophylaxis, we sought to determine whether aspirin prescribed (ASA) is safe and effective in obese patients undergoing RTHA/RTKA. METHODS A retrospective review of 1578 consecutive RTHA/RTKA cases (751 RTHAs and 827 RTKAs) was conducted identifying patients prescribed 325 or 81 mg ASA. Ninety-day postoperative VTE rates, bleeding, wound complications, deep infections, and mortality were collected. Cohorts were stratified according to body mass index (BMI): normal (18-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2), severely obese (35-39.9 kg/m2), and morbidly obese (≥40 kg/m2). RESULTS The cohort comprised of 335 patients with a normal BMI, 511 were overweight, 408 obese, 232 severely obese, and 92 morbidly obese. Total VTE rates were statistically similar between BMI groups (0.90% vs 0.78% vs 0.74% vs 0.43% vs 0%, P = .89). There were no differences in bleeding rates (0.90% vs 0% vs 0% vs 0.43% vs 0%, P = .08), wound complications (0.30% vs 0.20% vs 0.25% vs 0% vs 0%, P = .93), infection (1.49% vs 1.57% vs 0.98% vs 1.29% vs 1.09%, P = .66), or mortality (0% vs 0.20% vs 0% vs 0% vs 0%, P = .72). CONCLUSION ASA is safe and effective for VTE prevention in obese patients with similar complication rates to nonobese patients undergoing RTHA/RTKA.
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15
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Kim KI, Kim GB, Lee MG, Song SJ. Do We Need Chemoprophylaxis to Prevent Venous Thromboembolism following Medial Open-Wedge High Tibial Osteotomy? J Knee Surg 2021; 34:1007-1013. [PMID: 31931550 DOI: 10.1055/s-0039-1700976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to investigate the overall incidence of venous thromboembolism (VTE) and to assess the efficacy of chemoprophylaxis to prevent VTE following medial open-wedge high tibial osteotomy (MOWHTO) in Asian patients. A total of 133 patients who consecutively underwent MOWHTO for the treatment of knee osteoarthritis with varus deformity were enrolled. All patients underwent preoperative ultrasonography and computed tomography venography on postoperative day 5 to detect deep vein thrombosis (DVT). Patients were divided into two groups: chemoprophylaxis group included patients (n = 66) who received 2.5 mg fondaparinux for 5 days postoperatively, whereas control group comprised patients (n = 67) who received placebo (67 patients). We evaluated the efficacy and safety outcomes of the treatment. We also assessed the predisposing factors that may affect the occurrence of VTE. The incidence of overall DVT was 14.9% in the control group and 10.6% in the chemoprophylaxis group (p > 0.05). Proximal DVT occurred in one patient in the control group. There was no symptomatic DVT or pulmonary embolism in either group. The patients with DVT had significantly higher mean body mass index (BMI) than the patients without DVT. Multivariate logistic regression showed BMI > 30 kg/m2 that was significantly correlated with the development of DVT (odds ratio = 0.8; p = 0.017). There were no cases of major bleeding; however, minor bleeding episodes occurred in four patients in the chemoprophylaxis group. The current study showed that the overall incidence of VTE following MOWHTO was low in Asian patients even without chemoprophylaxis. Therefore, routine chemoprophylaxis following MOWHTO seems to be not necessary in a population with low-VTE incidence. However, selective chemoprophylaxis should be considered in patients with BMI > 30 kg/m2.
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Affiliation(s)
- Kang-Il Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Republic of Korea.,Department of Orthopedic Surgery, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, Republic of Korea
| | - Gi Beom Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Republic of Korea
| | - Myeong Gu Lee
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Republic of Korea
| | - Sang Jun Song
- Department of Orthopedic Surgery, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, Republic of Korea
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16
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Cao Q, He Z, Fan Y, Meng J, Yuan T, Zhao J, Bao N. Effects of tourniquet application on enhanced recovery after surgery (ERAS) and ischemia-reperfusion post-total knee arthroplasty: Full- versus second half-course application. J Orthop Surg (Hong Kong) 2020; 28:2309499019896026. [PMID: 31965906 DOI: 10.1177/2309499019896026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Qinggang Cao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Zhiwei He
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Yongfei Fan
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jia Meng
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Tao Yuan
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Jianning Zhao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
| | - Nirong Bao
- Department of Orthopaedic Surgery, Jinling Hospital, Nanjing, China
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17
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Mian O, Matino D, Roberts R, McDonald E, Chan AKC, Chan HHW. Potential Risk Factors Contributing to Development of Venous Thromboembolism for Total Knee Replacements Patients Prophylaxed With Rivaroxaban: A Retrospective Case-Control Study. Clin Appl Thromb Hemost 2020; 26:1076029620962226. [PMID: 33064561 PMCID: PMC7573710 DOI: 10.1177/1076029620962226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rivaroxaban after total knee arthroplasty (TKA) is used to prevent postoperative venous thromboembolism (VTE); however, despite thromboprophylaxis, some patients still develop postoperative VTE. To determine whether tourniquet time, time to initiate rivaroxaban (TTIRIV), or Body Mass Index (BMI) was associated with postoperative VTE. A retrospective case-control study was conducted. Those patients that developed VTE despite prophylaxis (cases) were compared to controls (no VTE). A univariate analysis was conducted (p < 0.05 statistically significant). Seven VTE cases were identified from 234 TKA-patients. Patients with and without VTE had BMI of 40.1 ± 9.1 and 32.8 ± 7.5, respectively (p = 0.064). TTIRIV in VTE and control group was 28.2 ± 4.7 hours and 26.4 ± 4.2 hours, respectively (p = 0.39). Mean tourniquet time in VTE and control group was 65.0 ± 8.7 minutes and 49 ± 8.8 minutes, respectively (p = 0.0007). Statistically significant differences in tourniquet times were noted between VTE and non-VTE group but not for TTIRIV and BMI. Prolonged tourniquet use could pose a potential risk factor for postoperative VTE. Thromboprophylaxis management may need to be adjusted, based on patient-specific factors that could include increasing doses of oral anticoagulants and/or mechanical prophylaxis. However, further large-scale studies are required to establish pathophysiology.
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Affiliation(s)
- Owais Mian
- Faculty of Medicine, University of Ottawa, Ontario, Canada.,Pediatric Thrombosis and Hemostasis Program, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Davide Matino
- Pediatric Thrombosis and Hemostasis Program, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Robin Roberts
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Ellen McDonald
- National Platform Research, McMaster University, Hamilton, Ontario, Canada
| | - Anthony K C Chan
- Pediatric Thrombosis and Hemostasis Program, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Howard H W Chan
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People's Republic of China
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18
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Park JY, Kim SE, Lee MC, Han HS. Elastic pneumatic tourniquet cuff can reduce postoperative thigh pain after total knee arthroplasty: a prospective randomized trial. BMC Musculoskelet Disord 2020; 21:565. [PMID: 32825814 PMCID: PMC7442977 DOI: 10.1186/s12891-020-03579-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background Tourniquet use is associated with complications such as thigh pain, skin problems, and deep vein thrombosis (DVT). This prospective study aimed to evaluate the efficacy and safety of the pneumatic tourniquet system using an elastic cuff and limb occlusion pressure (LOP) in total knee arthroplasty (TKA). The hypothesis of this study was that an elastic cuff tourniquet would result in less postoperative thigh pain after TKA. Methods This prospective randomized controlled trial involved a total of 98 patients who underwent primary TKA. They were randomized into two groups: tourniquet system using an elastic cuff and LOP group (Group E) and tourniquet system using a conventional-cuff and LOP group (Group C). Outcomes including postoperative thigh pain assessed using a visual analog scale (VAS), serum muscle enzymes, recommended tourniquet pressure (RTP), bloodlessness of surgical field, surgical time, incidence of DVT, and the frequency of rescue analgesic use after surgery, were compared between groups. Results Patients in Group E experienced significantly less thigh pain compared to those in Group C on postoperative day 4 (P = 0.01) and day 7 (P = 0.04). The difference between RTP and systolic blood pressure was significantly lower in Group E (P = 0.045). One case of thigh DVT was found in Group E, while no such cases were found in Group C. One and two cases of poor bloodless surgical fields were observed in Group E and Group C, respectively. There was no significant difference in surgical time, levels of serum muscle enzymes, and the frequency of rescue analgesic use between the two groups. Conclusions The pneumatic tourniquet system using an elastic cuff and LOP reduced early postoperative thigh pain more effectively than did the tourniquet system using a conventional cuff and LOP. Trial registration #KCT0003149. Registered August 17, 2018 - Retrospectively registered.
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Affiliation(s)
- Jae-Young Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sung Eun Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Lu Y, Cregar WM, Goodloe JB, Khazi Z, Forsythe B, Gerlinger TL. General Anesthesia Leads to Increased Adverse Events Compared With Spinal Anesthesia in Patients Undergoing Unicompartmental Knee Arthroplasty. J Arthroplasty 2020; 35:2002-2008. [PMID: 32247674 DOI: 10.1016/j.arth.2020.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The volume of unicompartmental knee arthroplasty (UKA) has increased dramatically in recent years with good reported long-term outcomes. UKA can be performed under general or neuraxial (ie, spinal) anesthesia; however, little is known as to whether there is a difference in outcomes based on anesthesia type. The purpose of the present study is to compare perioperative outcomes between anesthesia types for patients undergoing primary elective UKA. METHODS Patients who underwent primary elective UKA from 2007 to 2017 were identified from the American College of Surgeons-National Surgical Quality Improvement Program Database. Operating room times, length of stay (LOS), 30-day adverse events, and readmission rates were compared between patients who received general anesthesia and those who received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics. RESULTS A total of 8639 patients underwent UKA and met the inclusion criteria for this study. Of these, 4728 patients (54.7%) received general anesthesia and 3911 patients (45.3%) received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia was associated with increased operative time (P < .001) and the occurrence of any severe adverse event (odds ratio [OR], 1.39; 95% confidence interval [95% CI], 1.04-1.84; P = .024). In addition, general anesthesia was associated with higher rates of deep venous thrombosis (OR, 2.26; 95% CI, 1.11-4.6; P = .024) and superficial surgical site infection (OR, 1.04; 95% CI, 0.6-1.81; P < .001). Finally, general anesthesia was also associated with a reduced likelihood of discharge to home (OR, 0.72; 95% CI, 0.59-0.88; P < .001). No difference existed in postoperative hospital LOS or readmission rates among cohorts. CONCLUSION General anesthesia was associated with an increased rate of adverse events and increased operating room times as well as a reduced likelihood of discharge to home. There was no difference in hospital LOS or postoperative readmission rates between anesthesia types.
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Affiliation(s)
- Yining Lu
- Division of Orthopaedics, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - William M Cregar
- Division of Orthopaedics, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - J Brett Goodloe
- Department of Orthopaedic Surgery and Physical Rehabilitation, Medical University of South Carolina, Charleston, SC
| | - Zain Khazi
- Department of Orthopaedic Surgery and Rehabilitation, Iowa University Hospitals and Clinics, Iowa City, IA
| | - Brian Forsythe
- Division of Orthopaedics, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - Tad L Gerlinger
- Division of Orthopaedics, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
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20
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Vakharia RM, Adams CT, Anoushiravani AA, Ehiorobo JO, Mont MA, Roche MW. Chronic Obstructive Pulmonary Disease Is Associated With Higher Rates of Venous Thromboemboli Following Primary Total Knee Arthroplasty. J Arthroplasty 2020; 35:2066-2071.e9. [PMID: 32349891 DOI: 10.1016/j.arth.2020.03.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/24/2020] [Accepted: 03/31/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is discordance in the literature regarding the presence of chronic obstructive pulmonary disease (COPD) and the development of venous thromboemboli (VTEs). Therefore, the purpose of this study is to determine whether COPD patients undergoing primary total knee arthroplasty (TKA) have higher rates of (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) VTEs; and (4) costs of care. METHODS COPD patients undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, gender, and medical comorbidities. Patients with a history of VTEs or hypercoagulable states were excluded. The query yielded 211,378 patients in the study (n = 35,230) and control (n = 176,148) cohorts. Outcomes analyzed included in-hospital LOS, readmission rates, VTEs, and costs of care. A P-value less than .01 was considered statistically significant. RESULTS COPD patients were found to have significantly longer in-hospital LOS (4 vs 3 days, P < .0001). Study group patients were also found to have significantly higher incidence and odds ratio (OR) of readmission rates (20.9% vs 16.3%; OR 1.36, P < .0001) and VTEs (1.75 vs .93; OR 1.18, P < .0001). Additionally, the study demonstrated that COPD patients incurred higher 90-day episode-of-care costs ($15,626.85 vs $14,471.29, P < .0001). CONCLUSION After adjusting for confounding variables, our study found an association between COPD and higher rates of developing VTEs following primary TKA. The study can be used by orthopedic surgeons to adequately counsel and educate these patients of the potential complications which may arise following their TKA.
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Affiliation(s)
- Rushabh M Vakharia
- Department of Orthopaedic Surgery, Holy Cross Hospital, Orthopaedic Research Institute, Fort Lauderdale, FL
| | - Curtis T Adams
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, NY
| | | | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Michael A Mont
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY; Department of Orthopaedic Surgery, Cleveland Clinic Hospital, Cleveland, OH
| | - Martin W Roche
- Department of Orthopaedic Surgery, Holy Cross Hospital, Orthopaedic Research Institute, Fort Lauderdale, FL
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What Factors Influence Operative Time in Total Knee Arthroplasty? A 10-Year Analysis in a National Sample. J Arthroplasty 2020; 35:621-627. [PMID: 31767239 DOI: 10.1016/j.arth.2019.10.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Changes in reimbursement in total knee arthroplasty (TKA) by Centers for Medicare and Medicaid Services (CMS) have been tied to a perceived decrease in the total surgical time required to perform these operations. However, little information is available to CMS about recorded surgical times for TKA across the United States and the variables that drive these values. Therefore, the purpose of our study, is to evaluate (1) changes in operative time over time and (2) factors associated with variations in operative time. METHODS The National Surgical Quality Improvement Program database was queried to identify all primary TKAs conducted between January 1, 2008, and December 31, 2017. All TKAs conducted within our study period that had operative time data available were included. Multivariable linear models were created to assess factors that influence operative time over the study period. RESULTS Our final analysis included 140,890 TKAs. The mean operative time across the study period was found to be 92.60 minutes. Examining quarterly values, operative time stayed within 5 minutes of this mean (range, 89.80-97.51 minutes). Age, sex, functional status, anesthesia type, body mass index, operative year, transfusion requirements, and preoperative laboratory findings significantly influenced operative time (P < .05 for all). CONCLUSION Our analysis indicates that while there are numerous factors that influence procedure duration, operative times have remained stable. This information should be heavily considered in regard to physician reimbursement, because providers are maintaining operative times and work effort while mitigating factors that influence outcomes in the perioperative period.
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Conversion Total Knee Arthroplasty: A Distinct Surgical Procedure With Increased Resource Utilization. J Arthroplasty 2019; 34:S114-S120. [PMID: 30824294 DOI: 10.1016/j.arth.2019.01.070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Current Procedural Terminology coding currently makes no distinction between primary total knee arthroplasty (TKA) and conversion TKA, in which periarticular hardware components must be removed prior to or during TKA. We hypothesize that conversion TKA will carry increased operative time, blood loss, postoperative complications, and 90-day emergency department/readmission rate compared to primary TKA. METHODS Patients undergoing conversion TKA from 2005 to 2017 were identified from an institutional database and matched to primary TKA patients by age, gender, American Society of Anesthesiologists score, body mass index, and procedure date (±1 year). Intraoperative data and 90-day postoperative complications were compared between groups. RESULTS One hundred nine conversion TKA patients with periarticular hardware were removed prior to (n = 51) or during (n = 58) TKA and 109 primary TKA control patients were included. Conversion TKA was associated with increased tourniquet time (91 vs 71 minutes, P < .001), operative time (147 vs 113 minutes, P < .001), blood loss (225 vs 176 mL, P = .010), 90-day readmissions (14.6% vs 4.2%, P = .020), wound complication (5.6% vs 0.0%, P = .025), periprosthetic joint infection (7.9% vs 0.0%, P = .005), irrigation/debridement (9.0% vs 1.1%, P = .016), and a trend toward increased mechanical complication (6.7% vs 1.1%, P = .058). Timing of hardware removal did not affect intraoperative or postoperative outcomes. CONCLUSION Conversion TKA is associated with higher operative time, blood loss, readmission rate, and postoperative complications compared to primary TKA. Without a proper billing code and appropriate reimbursement level to match the expected operative and postacute resource utilization by these cases, physicians may be disincentivized to perform these operations.
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Abstract
BACKGROUND Although tourniquets are commonly used during TKA, that practice has long been surrounded by controversy. Quantifying the case for or against tourniquet use in TKA, in terms of patient-reported outcomes such as postoperative pain, is a priority. QUESTIONS/PURPOSES The purpose of this study was to meta-analyze the available randomized trials on tourniquet use during TKA to determine whether use of a tourniquet during TKA (either for the entire procedure or some portion of it) is associated with (1) increased postoperative pain; (2) decreased ROM; and (3) longer lengths of hospital stay (LOS) compared with TKAs performed without a tourniquet. METHODS We completed a systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines to assess the impact of tourniquet use on patients after TKA. We searched the following databases from inception to February 1, 2015, for randomized controlled trials meeting prespecified inclusion criteria: PubMed, Embase, and Cochrane Central Register of Controlled Trials. Postoperative pain was the primary outcome. Secondary outcomes were postoperative ROM and LOS. The initial search yielded 218 studies, of which 14 met the inclusion criteria. For our primary analysis on pain and ROM, a total of eight studies (221 patients in the tourniquet group, 219 patients in the no-tourniquet group) were meta-analyzed. We also performed a subgroup meta-analysis on two studies that used the tourniquet only for a portion of the procedure (from osteotomy until the leg was wrapped with bandages) and defined this as half-course tourniquet use (n = 62 in this analysis). The Jadad scale was used to ascertain methodological quality, which ranged from 3 to 5 with a maximum possible score of 5. Statistical heterogeneity was tested with I and chi-square tests. A fixed-effects (inverse variance) model was used when the effects were homogenous, which was only the case for postoperative pain; the other endpoints had moderate or high levels of heterogeneity. Publication bias was assessed using a funnel plot, and postoperative pain showed no evidence of publication bias, but the endpoint of LOS may have suffered from publication bias or poor methodological quality. We defined the minimum clinically important difference (MCID) in pain as 20 mm on the 100-mm visual analog scale (VAS). RESULTS We found no clinically important difference in mean pain scores between patients treated with a tourniquet and those treated without one (5.23 ± 1.94 cm versus 3.78 ± 1.61 cm; standardized [STD] mean difference 0.88 cm; 95% confidence interval [CI], 0.54-1.23; p < 0.001). None of the studies met the MCID of 20 mm in VAS pain scores. There was also no clinically important difference in ROM based on degrees of flexion between the two groups (49 ± 21 versus 56 ± 22; STD mean difference 0.8; 95% CI, 0.4-1.1; p < 0.001). Similarly, we found no difference in mean LOS between groups (5.8 ± 4.4 versus 5.9 ± 4.6; STD mean difference -0.2; 95% CI, -0.4 to 0.1; p = 0.25). A subgroup meta-analysis also showed no clinically important difference in pain between the full-course and half-course tourniquet groups (5.17 ± 0.98 cm versus 4.09 ± 1.08 cm; STD mean difference 1.31 cm; 95% CI, -0.16 to 2.78; p = 0.08). CONCLUSIONS We found no clinically important differences in pain or ROM between patients treated with and without tourniquets during TKA and no differences between the groups in terms of LOS. In the absence of short-term benefits of avoiding tourniquets, long-term harms must be considered; it is possible that use of a tourniquet improves a surgeon's visualization of the operative field and the quality of the cement technique, either of which may improve the long-term survivorship or patient function, but those endpoints could not be assessed here. We recommend that the randomized trials discussed in this meta-analysis follow patients from the original series to determine if there might be any long-term differences in pain or ROM after tourniquet use. LEVEL OF EVIDENCE Level I, therapeutic study.
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Impact of resident participation on outcomes following lumbar fusion: An analysis of 5655 patients from the ACS-NSQIP database. J Clin Neurosci 2018; 56:131-136. [DOI: 10.1016/j.jocn.2018.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 05/01/2018] [Accepted: 06/19/2018] [Indexed: 01/21/2023]
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George J, Mahmood B, Sultan AA, Sodhi N, Mont MA, Higuera CA, Stearns KL. How Fast Should a Total Knee Arthroplasty Be Performed? An Analysis of 140,199 Surgeries. J Arthroplasty 2018; 33:2616-2622. [PMID: 29656973 DOI: 10.1016/j.arth.2018.03.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 02/27/2018] [Accepted: 03/06/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although previous studies have shown that prolonged operative times can lead to an increased risk of complications after total knee arthroplasty (TKA), they only evaluated a few complications. It is also unclear whether a distinctive operative time exists after which complications increase. Therefore, this study was performed to (1) assess whether higher operative time increases the risk of complications within 30 days of TKA and (2) explore the relationship between operative time and various complications to identify possible operative times where complication rates increase. METHODS The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 140,199 primary TKAs. The effect of operative time (skin-to-skin) on various medical and surgical complications within 30 days was evaluated using multivariable logistic regression models. Spline regression models were created to further study the relationship between operative time and complications. RESULTS After adjusting for confounding factors, longer operative times were associated with higher risks of readmission (P < .001), reoperation (P < .001), surgical site infection (P < .001), wound dehiscence (P < .001), and transfusion (P < .001). The majority of the complications demonstrated an increase throughout the range of operative time, with a slightly pronounced increase in the risk of complications when the operative time was longer than 80 minutes. CONCLUSION Prolonged operative times were associated with an increased risk of a number of important complications such as readmissions, reoperations, surgical site infections, and wound complications. Based on our results, an operative time goal of less than 80 minutes is helpful for minimizing these complications after TKA.
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Affiliation(s)
- Jaiben George
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Bilal Mahmood
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Assem A Sultan
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nipun Sodhi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kim L Stearns
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Lee JE, Jung DH, Yang JM, Lee WK, Jeon Y, Kim SO. Comparison of the incidence of venous thromboembolism between epidural and general anesthesia for total knee arthroplasty: a retrospective study. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.2.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jeong Eun Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong-ho Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae-Min Yang
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Won Kee Lee
- Medical Research Collabration Center in KNUH, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Younghoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
- School of Dentistry, Kyungpook National University, Daegu, Korea
| | - Si-Oh Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Ozkunt O, Sariyilmaz K, Gemalmaz HC, Dikici F. The effect of tourniquet usage on cement penetration in total knee arthroplasty: A prospective randomized study of 3 methods. Medicine (Baltimore) 2018; 97:e9668. [PMID: 29369184 PMCID: PMC5794368 DOI: 10.1097/md.0000000000009668] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Phan K, Kim JS, Capua JD, Lee NJ, Kothari P, Dowdell J, Overley SC, Guzman JZ, Cho SK. Impact of Operation Time on 30-Day Complications After Adult Spinal Deformity Surgery. Global Spine J 2017; 7:664-671. [PMID: 28989846 PMCID: PMC5624378 DOI: 10.1177/2192568217701110] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE There is a paucity of data on the effect of operative duration on postoperative complications during adult spinal deformity surgery (ASDS). The study attempts to explore and quantify the association between increased operation times and postoperative complications. METHODS A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing ASDS were separated into cohorts based on quartiles of operation duration. Chi-square and multivariate logistic regression models were used to identify risk factors. RESULTS A total of 5338 patients met the inclusion criteria and were divided per quartiles based on operative duration in minutes (154, 235, 346, and 1156 minutes). Multivariate logistic regressions revealed that in comparison to the lowest quartile of operative duration, the highest quartile group was associated significantly with length of stay ≥5 days (odds ratio [OR] = 5.85), any complication (OR = 9.88), wound complication (OR = 5.95), pulmonary complication (OR = 2.85, P = .001), venous thromboembolism (OR = 12.37), intra-/postoperative transfusion (OR = 12.77), sepsis (OR = 5.27), reoperations (OR = 1.48), and unplanned readmissions (OR = 1.29). The odds ratio was higher when comparing a higher quartile group with the reference group across all associations. P < .001 unless otherwise noted. CONCLUSION ASDS operation time is associated with multiple postoperative complications, including, but not limited to, wound and pulmonary complications, venous thromboembolism, postoperative transfusion, length of stay ≥5 days, sepsis, reoperation, and unplanned readmission.
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Affiliation(s)
- Kevin Phan
- University of New South Wales, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Di Capua
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Dowdell
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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Wang K, Ni S, Li Z, Zhong Q, Li R, Li H, Ke Y, Lin J. The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 2017; 25:2849-2857. [PMID: 26745962 DOI: 10.1007/s00167-015-3964-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 12/23/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Kai Wang
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Songjia Ni
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Zhichang Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Qunjie Zhong
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Rujun Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Hu Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Yan Ke
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China
| | - Jianhao Lin
- Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Xizhimen South Street No. 11, Beijing, China.
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Boylan MR, Perfetti DC, Kapadia BH, Delanois RE, Paulino CB, Mont MA. Venous Thromboembolic Disease in Revision vs Primary Total Knee Arthroplasty. J Arthroplasty 2017; 32:1996-1999. [PMID: 28209273 DOI: 10.1016/j.arth.2016.12.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 12/18/2016] [Accepted: 12/27/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Venous thromboembolic disease (VTED) is a serious complication of primary and revision total knee arthroplasty (TKA). However, the incidence and risk of VTED for revision compared with primary TKA cases have not been well-described. METHODS We identified 225,584 TKAs (208,954 primaries, 16,630 revisions) in the 2003-2012 Statewide Planning and Research Cooperative System database. Odds ratios (ORs) expressed the risk of VTED for revision vs primary TKA, and models were adjusted for age, gender, race, and Charlson comorbidity scores. Outcome analyses were further stratified into deep venous thromboses (DVTs) and pulmonary emboli (PEs). RESULTS The incidence of VTED within 30 days was 2.24% for primary and 1.84% for revision. In multivariable-adjusted regression, the OR of VTED within 30 days for revision compared with primary was 0.81 (95% confidence interval = 0.72-0.91; P < .001). The incidence of VTED within 90 days was 2.42% for primary and 2.13% for revision (P = .022), with a multivariable-adjusted OR of 0.87 (95% confidence interval = 0.78-0.97; P = .010) for revision compared with primary. The association was stronger for PE (OR = 0.63; P < .001) than DVT (OR = 0.87; P = .035) at 30 days, and significant for PE (OR = 0.69; P < .001), but not DVT (OR = 0.94; P = .284) at 90 days. CONCLUSION In a large statewide database, the risk of VTED was lower for revision TKA compared with primary TKA. The reasons for this observation are not known, but might be related to aggressive prophylactic management of patients undergoing revision procedures. Future studies should attempt to clarify differences in patient selection and management for primary vs revision procedures.
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Affiliation(s)
- Matthew R Boylan
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York; Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Dean C Perfetti
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Bhaveen H Kapadia
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Carl B Paulino
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Tiwari MK, Vaishya R, Agarwal AK, Vijay V. Tourniquet during total knee arthroplasty: A review. APOLLO MEDICINE 2017. [DOI: 10.1016/j.apme.2017.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Mori N, Kimura S, Onodera T, Iwasaki N, Nakagawa I, Masuda T. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: A prospective, randomized study. Knee 2016; 23:887-9. [PMID: 27372555 DOI: 10.1016/j.knee.2016.02.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 12/29/2015] [Accepted: 02/10/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND There has been controversy regarding the incidence of deep vein thrombosis (DVT) after total knee arthroplasty (TKA) with or without the use of a tourniquet. The aim of this randomized, prospective study was to clarify the effects of tourniquet use on DVT in TKA. METHODS The subjects were 109 patients scheduled to undergo TKA from April 2008 to March 2009 before the establishment of the American Association of Orthopedic Surgeons (AAOS) practice guidelines. They were randomized into two groups: 51 patients in the tourniquet group (group T) and 52 patients in the control group without a tourniquet (group C). We investigated the thrombotic presence using ultrasonography one week after surgery and compared both groups. RESULTS There was no difference in the rate of proximal DVTs (P=0.63). However, the risk of distal DVT was significantly higher in group T than in group C (52.9% vs. 23.1%; P=0.002). CONCLUSIONS Use of the tourniquet in TKA increased the risk of distal DVT.
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Affiliation(s)
- Noriaki Mori
- Department of Orthopaedic Surgery, Wajo Eniwa Hospital, Eniwa, Hokkaido, Japan.
| | - Shoichi Kimura
- Department of Orthopaedic Surgery, Wajo Eniwa Hospital, Eniwa, Hokkaido, Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Izumi Nakagawa
- Department of Cardiovascular Medicine, Wajo Eniwa Hospital, Eniwa, Hokkaido, Japan
| | - Takeshi Masuda
- Department of Orthopaedic Surgery, Wajo Eniwa Hospital, Eniwa, Hokkaido, Japan
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Tie K, Hu D, Qi Y, Wang H, Chen L. Effects of Tourniquet Release on Total Knee Arthroplasty. Orthopedics 2016; 39:e642-50. [PMID: 27286051 DOI: 10.3928/01477447-20160606-03] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/28/2015] [Indexed: 02/03/2023]
Abstract
This study investigated the clinical outcomes of early and late tourniquet release (tourniquet release after cementing the prosthesis vs tourniquet release after wound closure and pressure dressing) in total knee arthroplasty (TKA). The study was conducted by searching PubMed, Embase, Web of Science, and Cochrane Central databases for articles on randomized controlled trials comparing early and late tourniquet release in primary TKA that were published from 1966 to March 2015. Relevant data were extracted, and the Physiotherapy Evidence Database (PEDro) Scale was used to assess the methodologic quality. Stata software (StatCorp, College Station, Texas) was used to perform a meta-analysis. Sixteen articles were included with a total of 1073 patients and 1097 knees. For blood loss, there were no significant differences between the 2 groups in calculated blood loss, decrease in hemoglobin level, drop in hematocrit level, and measured postoperative blood loss, although total measured blood loss and postoperative blood transfusion rate were significantly higher in the early tourniquet release group than in the late tourniquet release group. No statistical differences were found for operative time and incidence of deep venous thrombosis (DVT) between the 2 groups. Wound complication rate in the early tourniquet release group was significantly lower than in the late tourniquet release group. Primary TKA with early tourniquet release is similar to TKA with late tourniquet release regarding perioperative blood loss, operative time, and incidence of DVT. Early tourniquet release reduced the incidence of wound complications compared with late tourniquet release. [Orthopedics. 2016; 39(4):e642-e650.].
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Complete Neurological Recovery After Transesophageal Echocardiography-Guided Diagnosis and Management of Prolonged Cardiopulmonary Resuscitation. ACTA ACUST UNITED AC 2016; 5:192-4. [PMID: 26588031 DOI: 10.1213/xaa.0000000000000210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 70-year-old man was scheduled for open reduction and internal fixation of his right knee fracture. When the tourniquet was deflated after 150 minutes, his arterial blood pressure and heart rate decreased precipitously. The patient was deemed to exhibit pulseless electrical activity. Cardiopulmonary resuscitation was initiated. The bispectral index reading improved to 25 to 30, but his end-tidal carbon dioxide was still very low (5 mm Hg). Transesophageal echocardiography showed a pulmonary embolism. Feedback from echo imaging improved the quality of chest compressions and motivated the resuscitation team to maintain the diastolic blood pressure>25 mm Hg. Although capnographic guidance was ineffective by itself, echocardiography monitoring was very helpful for showing the intracardiac events.
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Kumar N, Yadav C, Singh S, Kumar A, Vaithlingam A, Yadav S. Evaluation of pain in bilateral total knee replacement with and without tourniquet; a prospective randomized control trial. J Clin Orthop Trauma 2015; 6:85-8. [PMID: 25983513 PMCID: PMC4411338 DOI: 10.1016/j.jcot.2015.01.095] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/22/2015] [Indexed: 10/23/2022] Open
Abstract
AIM Thigh pain following tourniquet application is a common complaint in early post operative period following total knee arthroplasty. METHOD Post operative Thigh pain was evaluated in 30 consecutive simultaneous bilateral total knee arthroplasty patients between July 2013 and January 2014. Patient thigh pain was evaluated with the VAS score. The scale was applied on first, second, third day & second and six weeks after surgery. RESULT There were statistically significant difference in VAS score in non-tourniquet group on first, second, third post operative day. We did not find statistically significant difference at Second and Six weeks post operatively. CONCLUSION This Randomized trial demonstrates that non-tourniquet use in TKA has less early postoperative pain and leads to better recovery.
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Affiliation(s)
- Nishikant Kumar
- Senior Research Associate, AIIMS, India,Corresponding author. c/o Bipin Kumar; Sector-4/D, Quarter No. 1038, Bokarosteel city, Jharkhand, India.
| | - Chandrashekhar Yadav
- Professor Orthopaedics, All India Institute of Medical Sciences, AIIMS, New Delhi, India
| | - Swapnil Singh
- Professor Orthopaedics, All India Institute of Medical Sciences, AIIMS, New Delhi, India
| | - Ashok Kumar
- Professor Orthopaedics, All India Institute of Medical Sciences, AIIMS, New Delhi, India
| | - Aruljothi Vaithlingam
- Professor Orthopaedics, All India Institute of Medical Sciences, AIIMS, New Delhi, India
| | - Sanjay Yadav
- Professor Orthopaedics, All India Institute of Medical Sciences, AIIMS, New Delhi, India
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Harsten A, Bandholm T, Kehlet H, Toksvig-Larsen S. Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty; a randomized controlled trial. Knee 2015; 22:126-30. [PMID: 25648580 DOI: 10.1016/j.knee.2014.12.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/01/2014] [Accepted: 12/23/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Thigh tourniquet is commonly used in total knee arthroplasty (TKA) but may contribute to pain and muscle damage. Consequently, the reduction in knee-extension strength after TKA may be caused by quadriceps muscle ischaemia underneath the cuff. AIM To examine if not using a thigh tourniquet during surgery was more effective than using a thigh tourniquet in preserving knee-extension strength 48 h after fast-track TKA. METHODS A total of 64 patients undergoing TKA were randomized (1:1) to the use of tourniquet (T-group) or no tourniquet (NT-group). In the T-group the tourniquet cuff pressure was based on the patient's systolic pressure and a margin of 100 mm Hg. It was inflated immediately before surgery and deflated as soon as surgery ended. The primary outcome was the change in knee-extension strength from pre-surgery to 48 h after surgery (primary end point). Secondary outcomes were pain, nausea, length of hospital stay (LOS) and periarticular swelling. RESULTS Knee-extension strength 48 h after surgery was substantially reduced by about 90% in both groups, with no statistically significant difference between groups (mean difference 1.5 N/kg, 95% CI 1.3-1.6). Among the secondary outcomes, the T-group had less bleeding during surgery (56 vs. 182 mL, P<0.01) compared with the NT-group. There was no difference in postoperative haemoglobin levels, pain, nausea, LOS or periarticular swelling between the groups. CONCLUSION Not using a thigh tourniquet during surgery was not superior in preserving knee-extension strength at the primary endpoint 48 h after fast-track TKA, compared to using a tourniquet.
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Affiliation(s)
- Andreas Harsten
- Dept of Anesthesiology, Hässleholm Hospital and Lund University, Box 351, 281 25 Hässleholm, Sweden.
| | - Thomas Bandholm
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Dept of Physical Therapy, Denmark; Dept of Orthopedic Surgery, Hvidovre Hospital, University of Copenhagen, Denmark; Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Henrik Kehlet
- Lundbeck Centre for Fast-track Hip and Knee Arthroplasty, Denmark; Dept of Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Blegdamsvej 9, DK-2100, Denmark
| | - Sören Toksvig-Larsen
- Dept of Orthopedic Surgery, Hässleholm Hospital and Lund University, Box 351, 281 25 Hässleholm, Sweden
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Yi S, Tan J, Chen C, Chen H, Huang W. The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2014; 134:1469-1476. [DOI: doi 10.1007/s00402-014-2056-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Yi S, Tan J, Chen C, Chen H, Huang W. The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2014; 134:1469-76. [PMID: 25128975 DOI: 10.1007/s00402-014-2056-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Shixiong Yi
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
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Operative duration as an independent risk factor for postoperative complications in single-level lumbar fusion: an analysis of 4588 surgical cases. Spine (Phila Pa 1976) 2014; 39:510-20. [PMID: 24365901 DOI: 10.1097/brs.0000000000000163] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study. OBJECTIVE To estimate the impact of increasing surgical duration on outcomes after single-level lumbar fusion. SUMMARY OF BACKGROUND DATA Lumbar fusion is a widely used practice for the treatment of disability and chronic low back pain. Longer operative duration is shown to correlate with increased morbidity and mortality in various surgical disciplines, but no large-scale study has been performed to validate this relationship in lumbar spine surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program was retrospectively reviewed to identify all patients who underwent lumbar fusion procedures during 2006 to 2011. Thirty-day morbidity and mortality rates were reported on the basis of operative time, whereas multivariate logistic regression model was used to examine operative duration as an independent risk factor for outcomes. RESULTS A total of 4588 patients were included in the analysis. The mean operative duration for all patients was 197 ± 105 minutes. Our multivariate risk-adjusted regression models demonstrated that increasing operative time was associated with step-wise increase in risk for overall complications (odds ratio [OR], 2.09-5.73), medical complications (OR, 2.18-6.21), surgical complications (OR, 1.65-2.90), superficial surgical site infection (OR, 2.65-3.97), and postoperative transfusions (OR, 3.25-12.19). Operative duration of 5 hours or more was also associated with increased risk of reoperation (OR, 2.17), organ/space surgical site infection (OR, 9.72), sepsis/septic shock (OR, 4.41), wound dehiscence (OR, 10.98), and deep vein thrombosis (OR, 17.22). CONCLUSION Our data suggest that increasing operative duration is associated with a wide array of complications. Operative duration is, therefore, an important quality metric in the performance of lumbar fusion. Strategies to reduce operative time and further research to identify risk factors that are associated with longer surgical duration are needed for improved patient outcomes. LEVEL OF EVIDENCE 3.
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Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2014; 9:13. [PMID: 24602486 PMCID: PMC3973857 DOI: 10.1186/1749-799x-9-13] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 02/11/2014] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Liaobin Chen
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.
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Choi JS, Han HS, Choi YH, Kwon JH, Ahn HY. Comparison of Simultaneous and Alternate Bilateral Pneumatic Compression in Hemodynamic Effects and Thromboprophylaxis After Total Knee Arthroplasty. Clin Appl Thromb Hemost 2014; 21:653-60. [PMID: 24408881 DOI: 10.1177/1076029613518366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
In this randomized trial, we compared the hemodynamic effects of 2 different methods of bilateral sequential pneumatic compression (Simultaneous compression with Fixed cycling rate [SF] vs Alternate compression with Adjusted cycling rate [AA]) and investigated whether venous flow augmentation influenced deep vein thrombosis (DVT) development in patients undergoing total knee arthroplasty. Pneumatic compression was started on the operation day and applied to discharge. A total of 108 limbs was evaluated by computed tomographic angiography and duplex ultrasound. Augmented peak volume flow (P = .008), expelled total volume (P < .001), and expelled peak volume (P < .001) were significantly larger in group SF. The DVT developed in 35 (32.4%) limbs, and they were neither symptomatic nor ileofemoral in location. The enhanced hemodynamic parameters did not influence the DVT development. In conclusion, group SF showed superior hemodynamic efficacy, but this superiority may not be a surrogate for better thromboprophylaxis.
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Affiliation(s)
- Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Seoul, Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Seoul, Korea
| | - Young Ho Choi
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Seoul, Korea
| | - Jae Hyun Kwon
- Division of Interventional Radiology, Department of Radiology, Dongguk University Ilsan Hospital, Dongguk University, Gyeonggi-do, Korea
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University-Seoul, Seoul, Korea
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Bin Abd Razak HR, Tan HCA. The use of pneumatic tourniquets is safe in Asians undergoing total knee arthroplasty without anticoagulation. Knee 2014; 21:176-9. [PMID: 24029468 DOI: 10.1016/j.knee.2013.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/25/2013] [Accepted: 08/16/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND There has always been controversy surrounding the use of pneumatic tourniquets in total knee arthroplasty (TKA) as they have been implicated in venous thromboembolic events (VTE). We aimed to evaluate the incidence of clinically significant VTE in Asians who underwent conventional TKA under tourniquet throughout the duration of surgery, without post-operative chemical VTE prophylaxis, but using post-operative pneumatic compression devices. METHODS Five hundred and thirty-one patients of a single surgeon who underwent elective total knee arthroplasty were retrospectively reviewed. All patients had a tourniquet applied to the operated limb. None of the patients received chemoprophylaxis against VTE. Post-operatively, only symptomatic patients were referred for ultrasonography. The patients were then stratified according to the tourniquet time: <60, 61 to 90, 91 to 120, and >120 min. The overall incidence as well as the incidence of venous thromboembolic events for each group was then calculated. RESULTS Of the 531 patients reviewed, 3 patients suffered from deep venous thrombosis (DVT) while 1 patient developed a fatal pulmonary embolism (PE). Hence, the overall incidence of clinically significant VTE was 0.75%. The 3 patients with DVT had tourniquet time of 61 to 90 min while the patient with PE had a tourniquet time of more than 120 min. CONCLUSION With a low overall incidence of VTE, the use of tourniquet in Asians during conventional total knee arthroplasty appears safe when post-operative pneumatic compression devices are used instead of chemical VTE prophylaxis. However, the risk of VTE seems to increase with a tourniquet time of more than 60 min. LEVEL OF EVIDENCE Therapeutic studies, level III.
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Affiliation(s)
| | - Hwee Chye Andrew Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, 169608, Singapore
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Zhao Z, Wang S, Ma W, Kong G, Zhang S, Tang Y, Zhao Y. Diabetes mellitus increases the incidence of deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg 2014; 134:79-83. [PMID: 24276361 DOI: 10.1007/s00402-013-1894-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Many patients undergoing total knee arthroplasty (TKA) have diabetes mellitus, which may increase the risk of deep vein thrombosis (DVT) after TKA. We therefore assessed whether diabetes mellitus increased the incidence of DVT within 14 days after TKA. MATERIALS AND METHODS The incidence of DVT within 14 days of surgery was compared in diabetic and non-diabetic patients undergoing TKA in our hospital between June 2011 and February 2013. The relationships between diabetes mellitus and DVT were analyzed. RESULTS Of the 358 enrolled patients, 70 (19.6%) had diabetes and 288 (80.4%) did not. DVT occurred within 14 days in 198 patients, 52 of 70 (74.3%) in the diabetes group and 146 of 288 (50.7%) in the non-diabetes group (p = 0.012). DVT of the contralateral leg was observed in 16 and 50 patients, respectively (p = 0.452). Logistic regression analysis showed that the risk of DVT was 2.71-fold higher in patients with than without diabetes mellitus (95% CI 1.183-6.212, p = 0.018). There were no significant differences in age, gender, hypertension, BMI, duration of surgery, intra-operative blood loss, and duration of tourniquet between the two groups. CONCLUSIONS The incidence of DVT 14 days after TKA was significantly higher in patients with than without diabetes.
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Affiliation(s)
- Zhongyuan Zhao
- Department of the Joint and Bone Surgery, Yantaishan Hospital, No. 91, Jiefang Road, Yantai, 264001, Shandong, China,
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Chen S, Li J, Peng H, Zhou J, Fang H, Zheng H. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2013; 38:355-9. [PMID: 24258152 DOI: 10.1007/s00264-013-2177-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to explore the influence of a half-course tourniquet strategy on the peri-operative blood loss and early functional recovery in primary total knee arthroplasty. METHODS A prospective clinical randomised controlled study was carried out in which 64 patients were equally divided into two groups: half-course group and whole-course group. A series of indicators were observed and recorded. These included operation time, peri-operative blood loss, visual analogue scale (VAS) score of the thigh or knee, limb swelling index, rehabilitation progress and occurrence of deep venous thrombosis cases. RESULTS There was no significant difference in operation time between the two groups. The intra-operative blood loss was slightly more in the half-course group, while the difference was not significant. The post-operative blood loss and calculated blood loss were less in the half-course group and the difference was significant. The thigh VAS score, limb swelling and time intervals required for patients to achieve straight leg raises and 90° of knee flexion in the half-course group were better than in the whole-course group. No case of symptomatic deep venous thrombosis happened in this study, while occult incidence of deep venous thrombosis happened in both groups, but no significant difference between the groups was confirmed. CONCLUSIONS The half-course tourniquet strategy could decrease the total peri-operative blood loss in primary total knee arthroplasty. It was beneficial in helping patients to achieve earlier functional recovery by improving the pain experience and limb swelling early in the post-operative period.
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Affiliation(s)
- Sen Chen
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, People's Republic of China
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