The effects of tourniquet on cement penetration in total knee arthroplasty

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Reliability of two different measuring techniques with computer tomography for penetration and distribution of cement in the proximal tibia after total knee arthroplasty

BACKGROUND

To evaluate the reliability of two different techniques for measuring penetration and distribution of the cement mantle in the proximal tibia after total knee arthroplasty (TKA) with Computer Tomography (CT) in vivo.

METHODS

Standardized CT scans of the proximal tibia were taken 1 to 2 years after total knee arthroplasties implanted with a surface cementing technique. These prospectively acquired transversal CT images of the surface of the proximal tibia were divided into four quadrants and were assessed once manually and once with a numerical computing program (MATLAB® Update 2, The MathWorks, Inc.) based on Hounsfield Units by one of the researchers. The assessments were repeated by the same and a second researcher. The ratio cement/trabecular bone was calculated 1, 3 and 5 mm distal of the tibia tray per quadrant. Kruskall-Wallis tests with multiple pairwise comparisons (Dunn's test) were used to determine differences between the quadrants. Intra- and inter-rater reliability as well as the inter method reliability were assessed with the Intraclass Correlation Coefficient (ICC) per level of depth and with Bland-Altman plots.

RESULTS

A total of 92 CT scans were included. The intra- and inter-rater reliability of the manual method ranged from 0.22 and 0.52. The intra- and inter-rater reliability of the matlab method varied between 0.98 to 0.99. The median percentage cement measured with the matlab method 1 mm underneath the tibial tray varied between 82 and 88%; at 3 mm depth between 38 and 54% and at 5 mm between 15 and 25%. There was significantly (p < 0.05) less cement in the antero-medial quadrant compared to the antero-lateral and postero-lateral quadrant at 3 mm and 5 mm depth.

CONCLUSIONS

Distribution and penetration of cement in the proximal tibia in a total knee arthroplasty can be measured reliably with CT in combination with the matlab method presented in this manuscript. This method can be used for clinical purposes as well as for scientific research.

TRIAL REGISTRATION

METC-nr: 06-104 Dossier NL14807.098.06/versie 06.

Tibial cement mantle thickness is not affected by tourniquetless total knee arthroplasty when performed with tranexamic acid

PURPOSE

Evidence exists that tourniquet use leads to increased cement penetration in total knee arthroplasty (TKA) due to decreased blood and fat in the bone during cementation. The use of tranexamic acid (TXA) has led to decreased blood loss and transfusion rates. The purpose of this study was to determine if the use of a tourniquet while utilising modern TXA protocols affects the tibial cement mantle penetration.

METHODS

140 patients who underwent primary TKA with and without a tourniquet (70 in each group) were retrospectively reviewed. All patients received a standard TXA protocol. The primary outcome measure was cumulative depth of cement mantle penetration of the tibial plateau on post-operative radiographs. Secondary outcome measures included post-operative change in haemoglobin and hematocrit levels, blood loss, and transfusion rates.

RESULTS

There was no significant difference in age, sex, or pre-operative haemoglobin or hematocrit levels between groups. Tourniquet use resulted in significantly lower blood loss (100.0 mL versus 154.7 mL, p < 0.001), and significantly reduced drop in haemoglobin (1.8 g/dL vs 2.5 g/dL, p < 0.001) and hematocrit (5.7% vs 7.4%, p = 0.04) levels. However, depth of tibial cement mantle penetration did not differ between the tourniquet group (15.3 mm) and non-tourniquet group (15.0 mm, p value n.s.). No patient in either group required a blood transfusion.

CONCLUSIONS

Tourniquet use in primary TKA results in decreased blood loss and less change in pre-operative vs post-operative haemoglobin and hematocrit levels. However, with the use of TXA, not using a tourniquet resulted in similar cement mantle penetration around the tibial component as with a tourniquet.

Effect of lavage and brush preparation on cement penetration and primary stability in tibial unicompartmental total knee arthroplasty: An experimental cadaver study

BACKGROUND

Unicompartmental total knee arthroplasty (UKA) is a well-established treatment option for unicondylar osteoarthritis, and generally leads to better functional results than tricompartimental total knee arthroplasty (TKA). However, revision rates of UKAs are reported as being higher; a major reason for this is aseptic loosening of the tibial component due to implant-cement-bone interface fatigue. The objective of this study was to determine the effects of trabecular bone preparation, prior to implantation of tibial UKAs, on morphological and biomechanical outcomes in a cadaver study.

METHODS

Cemented UKAs were performed in 18 human cadaver knees after the bone bed was cleaned using pulsed lavage (Group A), conventional brush (Group B) or no cleaning at all (Group C, control). Morphologic cement penetration and primary stability were measured.

RESULTS

The area proportion under the tibial component without visible cement penetration was significantly higher in Group C (21.9%, SD 11.9) than in both Group A (7.1%, SD 5.8), and Group B (6.5%, SD 4.2) (P=0.007). The overall cement penetration depth did not differ between groups. However, in the posterior part, cement penetration depth was significantly higher in Group B (1.9mm, SD 0.3) than in both Group A (1.3mm, SD 0.3) and Group C (1.4mm, SD 0.3) (P=0.015). The mode of preparation did not show a substantial effect on primary stability tested under dynamic compression-shear test conditions (P=0.910).

CONCLUSION

Bone preparation significantly enhances cement interdigitation. The application of a brush shows similar results compared with the application of pulsed lavage.