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Gibbs B, Sniderman J, Mohammed S, Kain M, Freccero D, Abdeen A. Association Between Tourniquet Use and Patient-Reported Outcomes Following Total Knee Arthroplasty: A Multicenter Comparison. J Bone Joint Surg Am 2025; 107:976-984. [PMID: 40112083 DOI: 10.2106/jbjs.24.00266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is one of the most commonly performed elective procedures in North America. While advancements have been made in patient optimization, surgical technique, and implant design, tourniquet use remains a contentious issue as it relates to patient outcomes and postoperative experience. METHODS As part of the PEPPER trial, we identified 5,684 patients who underwent primary TKA, of whom 4,866 (85.6%) underwent surgery with a tourniquet (the YT group) and 818 (14.4%) underwent surgery without a tourniquet (the NT group). The cohort was predominantly female (60.8%), White (77%), and of an ethnicity other than Hispanic or Latino (96.8%). The mean age of the patients was 64.6 ± 9.2 years. The primary outcomes were the Knee injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR); Patient-Reported Outcomes Measurement Information System Physical Health Summary (PROMIS-PH10); and numeric pain rating scale (NPRS), which were captured preoperatively and at 1, 3, and 6 months postoperatively. The secondary outcomes were length of stay, discharge disposition, analgesic consumption, and postoperative complications. Multivariable analysis was performed to assess the associations between tourniquet use and patient-reported outcome measures (PROMs) following TKA. RESULTS The percentages of patients achieving the minimal clinically important difference (MCID) for the KOOS JR were significantly different at 1 month only (YT, 55.4%; NT, 47.9%). This difference disappeared at 3 and 6 months. There was no difference between the YT and NT groups in terms of the percentage of patients achieving the MCID for the PROMIS-PH10 or NPRS at any time point. There were no differences between the YT and NT groups at any time point with respect to the KOOS JR, PROMIS-PH10, and NPRS. There were no differences in opioid consumption, operative time, length of stay, wound-related complications, or readmissions postoperatively. CONCLUSIONS Tourniquet use was associated with more patients achieving the MCID for the KOOS JR at 1 month compared with no tourniquet use. This difference disappeared at 3 and 6 months. At 1, 3, and 6 months, there were no differences in opioid consumption, health-care utilization, or complications between patients undergoing TKA with a tourniquet versus without a tourniquet. Tourniquet use did not have a clinically meaningful impact on PROMs in the multivariable analysis. Arthroplasty surgeons may use these data during preoperative discussions with patients regarding tourniquet use as it relates to the surgeon's preference and how it could influence postoperative function. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brian Gibbs
- Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Jhase Sniderman
- Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shariq Mohammed
- Department of Biostatistics, Boston University, Boston, Massachusetts
- Rafik B. Hariri Institute for Computing and Computational Science and Engineering, Boston University, Boston, Massachusetts
| | - Michael Kain
- Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - David Freccero
- Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Ayesha Abdeen
- Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
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Wu W, Cao L, Sun K, Wang H. Comparing different timings of tourniquet application in total knee arthroplasty: effects on postoperative pain and bone cement interface. J Orthop Surg Res 2025; 20:59. [PMID: 39825387 PMCID: PMC11740488 DOI: 10.1186/s13018-025-05486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Accepted: 01/10/2025] [Indexed: 01/20/2025] Open
Abstract
OBJECTIVE This study aims to elucidate the impact of varying tourniquet application timings on postoperative pain and the bone cement interface following TKA. METHOD Patients who underwent TKA in our department between March 2021 and July 2023 were included in this study. They were randomly assigned to three groups: Group 1 used tourniquets throughout the operation, Group 2 applied tourniquets before the osteotomy, and Group 3 applied tourniquets after completing the osteotomy. The general epidemiological data, tourniquet pressure and duration, postoperative VAS scores, osteotomy surface preparation, blood loss, transfusion rate, KSS scores, knee flexion deformity, knee and thigh circumference differences, and perioperative complications were analyzed and compared among the three groups. RESULT There was no significant difference in the general epidemiological data among the three groups. At different times after the operation, VAS scores for the surgical site and tourniquet site were significantly different among the three groups. The three groups had similar osteotomy surface preparation before prosthesis installation. At two weeks, they differed significantly in knee flexion deformity. While the differences in knee circumference were not significant, Group 1 had a significantly larger thigh circumference difference than the other two groups at 24 h. The incidence of skin complications and DVT in Group 1 was significantly higher than that in Group 3. CONCLUSION The use of tourniquets after osteotomy can lead to a good bone cement interface and reduce postoperative leg pain, swelling, and complication rates.
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Affiliation(s)
- Wenbin Wu
- Department of Orthopaedics, FuyangHospital of Anhui Medical University, Fuyang, Anhui, China
| | - Le Cao
- Department of Orthopaedics, FuyangHospital of Anhui Medical University, Fuyang, Anhui, China
| | - Kai Sun
- Department of Orthopaedics, FuyangHospital of Anhui Medical University, Fuyang, Anhui, China
| | - Hongyi Wang
- Department of Orthopaedics, FuyangHospital of Anhui Medical University, Fuyang, Anhui, China.
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Ghandour S, Jain VK, Gupta A. Choosing ankle tourniquets in foot and ankle surgery: Beyond postoperative pain considerations. World J Orthop 2024; 15:828-830. [PMID: 39318490 PMCID: PMC11417627 DOI: 10.5312/wjo.v15.i9.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 08/07/2024] [Accepted: 08/09/2024] [Indexed: 09/12/2024] Open
Abstract
This editorial critically explores the use of ankle vs thigh tourniquets in foot and ankle surgery based on a recent study that found no significant difference in postoperative pain between the two placement techniques. Despite these findings, we argue for the preferential use of ankle tourniquets, highlighting their potential benefits in reducing venous blood stasis and minimizing soft tissue injury. This approach underscores the importance of considering long-term patient outcomes and vascular health beyond immediate postoperative pain. By integrating study findings with broader clinical considerations, we hereby advocate for a nuanced approach to tourniquet use that prioritizes patient safety and long-term recovery in conjunction with immediate postoperative pain.
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Affiliation(s)
- Samir Ghandour
- The Faculty of Medicine and Biomedical Sciences, The University of Balamand, Beirut 1100, Lebanon
| | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, Delhi 110001, India
| | - Ashim Gupta
- Department of Orthopaedics and Regenerative Medicine, Future Biologics, Lawrenceville, GA 30043, United States
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Natesan R, Istiyak M, Dhanasekara Raja P, Rajasekaran S. Optimizing Tourniquet Pressure in Primary Total Knee Arthroplasty: Limb Occlusion Pressure vs Systolic Blood Pressure Method: A Randomised Controlled Study. Indian J Orthop 2024; 58:971-978. [PMID: 38948377 PMCID: PMC11208337 DOI: 10.1007/s43465-024-01177-5] [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: 11/13/2023] [Accepted: 05/04/2024] [Indexed: 07/02/2024]
Abstract
Background This study aims to systematically compare the efficacy of two distinct approaches that is limb occlusion pressure (LOP) and systolic blood pressure (SBP) in determining the optimal tourniquet pressure for primary total knee arthroplasty. The overarching goal is to identify the method that yields superior outcomes in minimizing post-operative thigh pain while simultaneously reducing complications in our patient population. Methods 311 patients scheduled for primary total knee replacement (TKR) were randomized in two groups. Group A (LOP) had 154 patients and group B had 157 patients. In group A, LOP was determined for all patients. After adding the safety margin, the tourniquet pressure was determined which was kept during the procedure. By adding 150 mm Hg to SBP in group B, the tourniquet inflation pressure was ascertained. Postoperatively, thigh pain was evaluated from day 1 to day 3 and at 6 weeks. Results The average tourniquet pressure in group A patients having thigh circumference between 40 and 50 cm was 223.8 mm + - 19.8 mm Hg and in group B it was 262.1 + - 15.9 mm Hg (P < .01). Patients having thigh circumference between 51 and 60 cm had average tourniquet pressure of 240.07 + - 20.1 mm Hg in group A and 264.5 + - 17.4 mm Hg in group B (P < .01). The average tourniquet pressure for patients with thigh circumference more than 60 cm was 296 + /15.3 mm Hg in group A and 267.3 + /19.2 mm Hg in group B (P < 0.01). Conclusion Tourniquet pressure determination based on the limb occlusion pressure (LOP) method provide less postoperative thigh pain and better range of motion. Graphical Abstract Optimizing Tourniquet Pressure in Primary Total Knee Replacement: Limb Occlusion Pressure vs Systolic blood pressure method to minimize thigh pain.
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Affiliation(s)
- Rajkumar Natesan
- Department of Joint Replacement Surgery, Ganga Medical Centre and Hospital Pvt. Ltd. 313, Mettupalayam Road, Coimbatore, India
| | - Mohammad Istiyak
- Department of Joint Replacement Surgery, Ganga Medical Centre and Hospital Pvt. Ltd. 313, Mettupalayam Road, Coimbatore, India
| | - P. Dhanasekara Raja
- Department of Joint Replacement Surgery, Ganga Medical Centre and Hospital Pvt. Ltd. 313, Mettupalayam Road, Coimbatore, India
| | - Shanmuganathan Rajasekaran
- Department of Joint Replacement Surgery, Ganga Medical Centre and Hospital Pvt. Ltd. 313, Mettupalayam Road, Coimbatore, India
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Bayrak HC, Adiguzel IF, Demir M, Tarlacık AO. Tranexamic Acid and Tourniquet: Which Combination Reduces Blood Loss Most Effectively? Niger J Clin Pract 2024; 27:521-527. [PMID: 38679776 DOI: 10.4103/njcp.njcp_3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 02/27/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Blood loss during and after total knee arthroplasty (TKA) can lead to substantial morbidity and the need for blood transfusions. There are several methods to minimize blood loss and decrease transfusion rates in patients undergoing TKA. Tranexamic acid, an antifibrinolytic agent with known efficacy for achieving these goals, is combined with tourniquets to reduce bleeding in arthroplasty surgeries. Our study investigated the effects of various combinations of tranexamic acid and tourniquet use on bleeding in knee arthroplasty in 558 patients. AIM We aimed to determine the method that would provide the least blood loss and transfusion need in knee arthroplasty surgery. METHODS Between January 2018 and December 2022, 558 patients aged between 55 and 85 years underwent TKA surgery for grade 4 gonarthrosis in our clinic, and their decrease in hemoglobin value and whether they were transfused or not were analyzed. The patients were divided into four groups based on use of tranexamic acid and tourniquet. Demographic variables and patient data (body mass index, INR values, and preoperative hemoglobin values) were recorded. RESULTS There were 558 patients with a mean age of 68.19 (67 ± 6.949) years. In group 1, tranexamic acid was not used in 128 patients and tourniquet was used only during cementation; in group 2, in 132 patients, tranexamic acid was not used and tourniquet was used throughout the surgery; in group 3, in 158 patients, tranexamic acid was used and tourniquet was used throughout the surgery; in group 4, in 140 patients, tranexamic acid was used and tourniquet was used only during cementation. The decrease in hemoglobin value and transfusion rate was lowest in group 3 and highest in group 1. Besides, there was a greater decrease in hemoglobin value in group 2 than in group 4 and the transfusion rate was similar. CONCLUSIONS This clinical study showed that using tranexamic acid and a tourniquet throughout surgery significantly reduced the decrease in hemoglobin value and the need for transfusion.
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Affiliation(s)
- H C Bayrak
- Department of Orthopaedics and Traumatology, Eskisehir Yunus Emre State Hospital, Eskisehir, Turkey
| | - I F Adiguzel
- Department of Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - M Demir
- Department of Orthopaedics and Traumatology, Tokat Zile State Hospital, Tokat, Turkey
| | - A O Tarlacık
- Department of Orthopaedics and Traumatology, Eskisehir City Hospital, Eskişehir, Turkey
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Bohlen KE, Bieger R. [Unicondylar knee arthroplasty-trigger for outpatient arthroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:284-290. [PMID: 38451275 DOI: 10.1007/s00132-024-04485-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/08/2024]
Abstract
The combination of a reduction in surgical trauma in unicondylar knee arthroplasty compared to total knee arthroplasty and the introduction of a standardised enhanced recovery concept leads to a pre-, peri- and postoperative improvement in the patient's condition, which results in a reduction of the length of stay in hospital. In healthy, motivated patients, day-case or outpatient surgical treatment is possible under these circumstances.
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Affiliation(s)
- Karina E Bohlen
- Allgemeine Orthopädie und Zentrum für Endoprothetik, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland.
| | - Ralf Bieger
- Zentrum für Knie‑, Hüft‑, Schulter- und Ellenbogenchirurgie, Schön Klinik München Harlaching, München, Deutschland
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Hansen CW, Carlino EK, Saunee LA, Dasa V, Bhandutia AK. Modern Perioperative Pain Management Strategies to Minimize Opioids after Total Knee Arthroplasty. Orthop Clin North Am 2023; 54:359-368. [PMID: 37718075 DOI: 10.1016/j.ocl.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Total Knee Arthroplasty is associated with significant postoperative pain that can limit functional outcomes and patient satisfaction. In recent years, the standard of care for postoperative pain management has reduced reliance on opioids in favor of multimodal analgesia. These regimens consist of systemic medications such as COX-2 inhibitors, acetaminophen, corticosteroids, and gabapentinoids, as well as regional and local approaches such as peripheral nerve blocks and local infiltrative analgesics. Newer therapies, such as cryoneurolysis, are still being studied but have shown promising results. Additional studies are needed to determine the ideal pain regimen that will optimize pain control and eliminate the need for postoperative opioids.
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Affiliation(s)
- Charles W Hansen
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Elizabeth K Carlino
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA.
| | - Lauren A Saunee
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Vinod Dasa
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Amit K Bhandutia
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
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Dragosloveanu S, Dragosloveanu C, Petre M, Gherghe ME, Cotor DC. The Impact of Tourniquet Usage on TKA Outcome: A Single-Center Prospective Trial. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050870. [PMID: 37241102 DOI: 10.3390/medicina59050870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/03/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Total knee arthroplasties (TKAs) are the most effective surgical treatment for end-stage knee osteoarthritis. The tourniquet is used to reduce intraoperative blood loss, improving surgical field visualization. There is much controversy regarding the effectiveness and safety of using a tourniquet during total knee arthroplasties. The purpose of this prospective study is to determine the effect of tourniquet usage during TKAs on early functional outcomes and pain in our center. Materials and Methods: We conducted a randomized controlled trial of patients following a primary total knee replacement between October 2020 and August 2021. We recorded presurgical data, which included age, sex and knee range of motion. Intraoperatively, we measured the amount of blood aspiration and the surgical room time. After the surgery, we measured the amount of blood aspirated through the drains and the hemoglobin. We measured flexion, extension, Visual Analogue Scale (VAS) scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC score) scores for the functional evaluation. Results: We included 96 patients in the T group and 94 in the NT group, respectively, who remained until the last follow-up. Regarding blood loss, the NT group demonstrated significantly lower levels: 245 ± 97.8 mL intraoperative and 324.8 ± 151.65 mL postoperative, compared to the T group, where we recorded 276 ± 109.2 mL during the surgical procedures and 353.44 ± 101.55 mL after the surgery, (p < 0.05). We also recorded significantly shorter operative room time for the NT group, (p < 0.05). During the follow-up, we noticed postoperative improvements but without significant differences between the groups. Conclusions: We found a significant decrease in bleeding after no tourniquet usage during total knee replacements and shorter operative times. On the other hand, the knee function demonstrated no significant differences between the groups. Further studies may be required in order to assess complications.
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Affiliation(s)
- Serban Dragosloveanu
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
- "Carol Davila" Faculty of Medicine, University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Christiana Dragosloveanu
- "Carol Davila" Faculty of Medicine, University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Clinical Hospital for Ophthalmological Emergencies, 030167 Bucharest, Romania
| | - Mihnea Petre
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
| | - Mihai E Gherghe
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
| | - Dragos C Cotor
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
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Stocks GW, Odoemene M, Gex J, Vidal EA, Sawyer K, Jones SL, Thompson B, Laughlin MS. Quadriceps Strain and TKA: Contribution of the Tourniquet and Intramedullary Rod to Postoperative Thigh Pain: A Randomized Controlled Trial. J Bone Joint Surg Am 2023; 105:455-461. [PMID: 36728455 DOI: 10.2106/jbjs.22.00703] [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: 02/03/2023]
Abstract
BACKGROUND Thigh pain is relatively common after total knee arthroplasty (TKA) and has been attributed to compression of the thigh muscles by the tourniquet used during surgery. Thigh pain that occurs after a TKA that was performed without a tourniquet may be due to a strain of the quadriceps muscle or insertion of the intramedullary (IM) rod. The purpose of the present study was to determine the cause of thigh pain after TKA in a randomized controlled trial evaluating tourniquet use, IM rod use, and quadriceps strain. METHODS This prospective randomized controlled trial enrolled 97 subjects undergoing primary knee arthroplasty into 4 groups according to tourniquet use (yes or no) and IM rod use (yes or no). Quadriceps strain was evaluated with magnetic resonance imaging (MRI) on postoperative day 1 (POD 1). Data collected preoperatively, intraoperatively, and postoperatively until the 6-week clinical visit included pain levels for the knee and thigh (recorded separately) and knee range of motion. RESULTS Regardless of tourniquet or IM rod use, 73 (75%) of the 97 patients reported thigh pain on POD 1. Thigh pain at 2 weeks postoperatively was indicative of a quadriceps strain. Use of a tourniquet and patient-reported thigh pain at 2 weeks increased the odds of a quadriceps strain, whereas IM rod use did not significantly contribute to thigh pain. CONCLUSIONS The etiology of thigh pain after TKA may be multifactorial; however, an iatrogenic quadriceps strain is one source of thigh pain after TKA, especially if the pain persists 2 weeks after surgery. LEVEL OF EVIDENCE Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gregory W Stocks
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas.,Fondren Orthopedic Research Institute (FORI), Houston, Texas
| | - Melissa Odoemene
- Fondren Orthopedic Research Institute (FORI), Houston, Texas.,McGovern Medical School, Houston, Texas
| | - Julia Gex
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas.,Fondren Orthopedic Research Institute (FORI), Houston, Texas
| | - Emily A Vidal
- Fondren Orthopedic Research Institute (FORI), Houston, Texas
| | | | | | - Brandon Thompson
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
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Hamawandi SA, Amin HI, Al-Humairi AK. Effects of the Use of Tourniquet in Total Knee Arthroplasty on the Clinical and Functional Outcomes with 5 Years of Follow-up: A Randomized Controlled Trial. J Knee Surg 2023; 36:222-230. [PMID: 34261160 DOI: 10.1055/s-0041-1731719] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of tourniquet in total knee arthroplasty (TKA) had a lot of controversies with no clear agreement about the advantages and disadvantages of tourniquet. This study aims to show the effects of tourniquet use in TKA on the functional and clinical outcomes with follow-up of 5 years. This is a randomized, double-blind, and single-center study of 101 patients who were treated by TKA and divided randomly into two groups. Tourniquet was used in group A and was not used in group B. Both groups were assessed by Knee Society score (KSS), knee injury and osteoarthritis outcome score (KOOS), visual analogue scale (VAS) score for thigh pain, and postoperative complications. Both groups were followed up for 5 years. The group of no tourniquet showed significant better functional outcomes measured by KSS at postoperative periods of 2 weeks (p = 0.001), 6 weeks (p = 0.006), and 3 months (p = 0.034), and KOOS at postoperative periods of 2 weeks (p = 0.001), 6 weeks (p =0.001), and 3 months (p = 0.016). However, there was no significant difference in long-term follow-up of 5 years. There were significantly better results with use of tourniquet regarding surgeon's visualization during surgery, less operative time, and less calculated blood loss, while significantly better results with no use of tourniquet were reported regarding less hospital stay, less postoperative analgesic consumption, and less postoperative thigh pain measured by VAS score at postoperative periods of day 1 (p = 0.001), day 5 (p = 0.001), 2 weeks (p = 0.001), and 6 weeks (p = 0.001). Regarding postoperative blood transfusion and clinical deep venous thrombosis, there was no significant difference between use of tourniquet or not. The evidence presented in this level-1 randomized controlled trial suggests that no use of tourniquet in TKA can improve functional outcomes in early postoperative period with no significant difference on functional outcome at 5 years of follow-up.
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Affiliation(s)
- Sherwan A Hamawandi
- Department of Orthopedic, College of Medicine, Hawler Medical University, Erbil, Iraq
| | - Hazhar I Amin
- Department of Orthopaedics, Erbil Teaching Hospital, Erbil, Iraq
| | - Ameer K Al-Humairi
- Department of Community Medicine, College of Medicine, University of Babylon, Hilla, Iraq
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Neufeld ME, McEwen JA, Kerr J, Sidhu A, Howard LC, Masri BA. Optimization of surgical tourniquet usage to improve patient outcomes: Translational cross-disciplinary implications of a surgical practice survey. Front Surg 2023; 10:1104603. [PMID: 37139190 PMCID: PMC10149658 DOI: 10.3389/fsurg.2023.1104603] [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: 12/06/2022] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
Tourniquet use is common practice in many millions of orthopaedic procedures annually. Recent reviews of risks and benefits of surgical tourniquet use have primarily involved meta-analyses, many of which have forgone a comprehensive risk-benefit analysis to simply question whether "tourniquet or no tourniquet" use produces improved patient outcomes, often leading to limited, inconclusive, or conflicting results. To investigate further, a pilot survey was undertaken to determine current practices, opinions, and understandings among orthopaedic surgeons in Canada regarding use of surgical tourniquets in total knee arthroplasties (TKAs). Results of the pilot survey showed a wide range of understanding and practice associated with tourniquet use in TKAs, especially regarding tourniquet pressures and tourniquet times, two key factors known from basic research and clinical studies to impact the safety and efficacy of tourniquet use. The wide variation of use indicated by the survey results reveals important implications for surgeons, researchers, educators, and biomedical engineers, to better understand the association between key tourniquet parameters and outcomes assessed in research, which may be factors leading to their often limited, inconclusive, and conflicting results. Lastly, we provide an overview of the overly simplified assessments of tourniquet use in meta-analyses, whose conclusions may not provide an understanding of how or whether key tourniquet parameters might be optimized to retain the benefits of tourniquet use while mitigating the associated real or perceived risks.
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Affiliation(s)
- Michael E. Neufeld
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Correspondence: Michael E. Neufeld
| | - James A. McEwen
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
- Western Clinical Engineering Ltd., Vancouver, BC, Canada
| | - Julie Kerr
- Western Clinical Engineering Ltd., Vancouver, BC, Canada
| | - Arsh Sidhu
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lisa C. Howard
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bassam A. Masri
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Magan AA, Dunseath O, Armonis P, Fontalis A, Kayani B, Haddad FS. Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials. J Exp Orthop 2022; 9:62. [PMID: 35776268 PMCID: PMC9249956 DOI: 10.1186/s40634-022-00485-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/12/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA. Methods A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate. Results 14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7–5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1–3.1) with an OR of 1.9 (95% CI = 1.1–3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12–0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4–5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10–0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7–9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50–19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60–3.60, p = 0.36) did not differ between the two groups. Conclusion Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use. Level of evidence meta-analysis, Level II.
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Affiliation(s)
- A A Magan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK. .,Department of Orthopaedic Surgery, The Princess Grace Hospital, 42-52 Nottingham Pl, Marylebone, London, W1U 5NY, UK.
| | - O Dunseath
- University College London, Gower St, London, WC1E 6BT, UK
| | - P Armonis
- University College London, Gower St, London, WC1E 6BT, UK
| | - A Fontalis
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - B Kayani
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - F S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, 42-52 Nottingham Pl, Marylebone, London, W1U 5NY, UK.,University College London, Gower St, London, WC1E 6BT, UK.,Institute of Sports, Health and Exercise, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
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Zhao J, Dong X, Zhang Z, Gao Q, Zhang Y, Song J, Niu S, Li T, Chen J, Wei FL. Association of Use of Tourniquets During Total Knee Arthroplasty in the Elderly Patients With Post-operative Pain and Return to Function. Front Public Health 2022; 10:825408. [PMID: 35359779 PMCID: PMC8960992 DOI: 10.3389/fpubh.2022.825408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/09/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE During total knee arthroplasty (TKA), tourniquet may negatively impact post-operative functional recovery. This study aimed at investigating the effects of tourniquet on pain and return to function. METHODS Pubmed, Embase, and Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15th, 2020. Search terms included; total knee arthroplasty, tourniquet, and randomized controlled trial. RCTs evaluating the efficacies of tourniquet during and after operation were selected. Two reviewers independently extracted the data. Effect estimates with 95% CIs were pooled using the random-effects model. Dichotomous data were calculated as relative risks (RR) with 95% confidence intervals (CI). Mean differences (MD) with 95% CI were used to measure the impact of consecutive results. Primary outcomes were the range of motion (ROM) and visual analog scale (VAS) pain scores. RESULTS Thirty-three RCTs involving a total of 2,393 patients were included in this study. The mean age is 65.58 years old. Compared to no tourniquet group, the use of a tourniquet resulted in suppressed ROM on the 3rd post-operative day [MD, -4.67; (95% CI, -8.00 to -1.35)] and the 1st post-operative month [MD, -3.18; (95% CI, -5.92 to -0.44)]. Pain increased significantly when using tourniquets on the third day after surgery [MD, 0.39; (95% CI, -0.19 to 0.59)]. Moreover, tourniquets can reduce intra-operative blood loss [MD, -127.67; (95% CI, -186.83 to -68.50)], shorter operation time [MD, -3.73; (95% CI, -5.98 to -1.48)], lower transfusion rate [RR, 0.85; (95% CI, 0.73-1.00)], higher superficial wound infection rates RR, 2.43; [(5% CI, 1.04-5.67)] and higher all complication rates [RR, 1.98; (95% CI, 1.22-3.22)]. CONCLUSION Moderate certainty evidence shows that the use of a tourniquet was associated with an increased risk of higher superficial wound infection rates and all complication rates. Therefore, the findings did not support the routine use of a tourniquet during TKA.
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Affiliation(s)
- Jian Zhao
- Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital (301 Hospital), Beijing, China
| | - Xin Dong
- Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Ziru Zhang
- Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Quanyou Gao
- Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yunfei Zhang
- Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Junlei Song
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital (301 Hospital), Beijing, China
| | - Shun Niu
- Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi'an, China
| | - Jiying Chen
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital (301 Hospital), Beijing, China
| | - Fei-Long Wei
- Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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Mateu Vicent D, Sola Ruano L, Cabré Serrés JL, Haro Fernandez D, Luna Gutiérrez R, Torra Parra M. Lower tourniquet pressure does not affect pain nor knee-extension strength in patients after total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2022; 30:1075-1081. [PMID: 33740110 DOI: 10.1007/s00167-021-06536-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The use of a tourniquet in total knee replacement has advantages and drawbacks. Some studies suggest that using ischaemia at low pressures could reduce its negative effects. Our objective is to verify whether the use of ischaemia at low pressures (100 mmHg above the systolic blood pressure) produces greater pain and loss of strength than surgery without a tourniquet. METHODS By the means of a prospective randomized clinical trial, patients were assigned to the control group (no tourniquet, NT) or the experimental group (tourniquet, T). The main variables measured were pain (VAS) and isometric muscle strength (preoperatively, 10 days and 3 months after surgery). Secondary variables were haemoglobin at 24 h, transfusion index, need for rescue drugs and days of admission. RESULTS A total of 71 patients (73 prosthesis) were studied. Both groups were homogeneous in terms of age, body mass index, sex ratio, preoperative strength and level of anesthetic risk. We did not find significative differences in any of the main variables (pain and strength) nor in the secondary ones. We could only find differences in the days of admission (2.77 vs. 3.05; p = 0.031). CONCLUSIONS Use of a tourniquet at low pressures (100 mmHg above systolic blood pressure) did not result in an increase in postoperative pain or a decrease in quadriceps extension force within the first 3 months after surgery. LEVEL OF EVIDENCE Level 1-Randomized controlled trial.
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Affiliation(s)
- David Mateu Vicent
- Servicio de Cirugía Ortopédica Y Traumatología, Hospital Universitario Mutua Terrassa, Tarrasa, Spain.
| | - Laura Sola Ruano
- Servicio de Rehabilitación, Hospital Universitario Mutua Terrassa, Tarrasa, Spain
| | - Josep Lluís Cabré Serrés
- Servicio de Cirugía Ortopédica Y Traumatología, Hospital Universitario Mutua Terrassa, Tarrasa, Spain
| | - Daniel Haro Fernandez
- Servicio de Cirugía Ortopédica Y Traumatología, Hospital Universitario Mutua Terrassa, Tarrasa, Spain
| | - Rodrigo Luna Gutiérrez
- Servicio de Cirugía Ortopédica Y Traumatología, Hospital Universitario Mutua Terrassa, Tarrasa, Spain
| | - Mercè Torra Parra
- Servicio de Rehabilitación, Hospital Universitario Mutua Terrassa, Tarrasa, Spain
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Sun C, Yang X, Zhang X, Ma Q, Yu P, Cai X, Zhou Y. Personalized tourniquet pressure may be a better choice than uniform tourniquet pressure during total knee arthroplasty: A PRISMA-compliant systematic review and meta-analysis of randomized-controlled trials. Medicine (Baltimore) 2022; 101:e28981. [PMID: 35212310 PMCID: PMC8878703 DOI: 10.1097/md.0000000000028981] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 01/18/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pneumatic tourniquets are widely used in total knee arthroplasty (TKA). Some surgeons prefer a uniform tourniquet inflation pressure (UTIP) for all patients; others use personalized tourniquet inflation pressures (PTIP) based on systolic blood pressure and limb occlusion pressure. However, no consensus exists regarding the optimal mode of inflation pressure during TKA. This review aimed to appraise if personalized tourniquet inflation pressures are better than uniform tourniquet inflation. METHODS The databases (Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang) were searched on March 2021 to systematically identify and screen the literature for randomized controlled trials involving PTIP and UTIP during total knee arthroplasty. RESULTS Thirteen randomized controlled trials, involving 1204 TKAs (1201 patients) were included in the systematic review. The meta-analysis identified a trend toward less visual analogue scale (VAS) score at rest with PTIP group at 1 day (P = .002), 2 to 3 days (P = .01), and less VAS score at activity 1 day (P < .0001), 2 to 3 days after the operation (P < .00001), and discharge (P < .0001). No significant difference was found between the groups in terms of VAS score at rest when discharge (P = 1.0). We also found no significant difference in terms of intraoperative blood loss (P = .48), total blood loss (P = .15), lower limb vein thrombosis (P = .42), and thigh bullae (P = .17). However, in the PTIP group, we found a significant higher hospital for special surgery (HSS) score (P = .007), broader knee Range of motion (P = .02), less rate of thigh ecchymosis (P = .00001), and shorter thigh circumference at 1 day (P = .006), 2 to 3 days (P = .0005), and discharge (P = .02). CONCLUSION PTIP provides a similar bloodless surgical field compared with the conventional UTIP. Furthermore, PTIP provides less pain intensity, thigh circumference, rate of thigh ecchymosis, higher hospital for special surgery, and better initial recovery of knee flexion in total knee arthroplasty. Therefore, we recommend using a PTIP method during TKA. More adequately powered and better-designed randomized controlled trials studies with long-term follow-up are required to produce evidence-based guidelines regarding the PTIP method.
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Affiliation(s)
- Changjiao Sun
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, China
| | - Xin Yang
- Department of Orthopedic, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, China
| | - Xiaofei Zhang
- Department of Clinical Epidemiology and Biostatistics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No.168 Litang Road, Dongxiaokou Town, Changping District, Beijing, China
| | - Qi Ma
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, China
| | - Peng Yu
- Department of Orthopedic, Wuhan University of Science and Technology Hospital, Qingling Street, Hongshan District, Wuhan, China
| | - Xu Cai
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, China
| | - Yonggang Zhou
- Department of Orthopaedic Surgery, The First Medical Centre, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, China
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Sun C, Zhang X, Ma Q, Tu Y, Cai X, Zhou Y. Impact of tourniquet during total knee arthroplasty when tranexamic acid was used: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2022; 17:18. [PMID: 35033124 PMCID: PMC8760757 DOI: 10.1186/s13018-021-02898-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/30/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction The efficacy of tourniquet use during primary total knee arthroplasty (TKA) is thought to reduce intraoperative blood loss, improve surgical exposure, and optimize cement fixation. Tranexamic acid (TXA) use can decrease postsurgical blood loss and transfusion requirements. This review aimed to appraise the effects of tourniquet use in TKA for patients with tranexamic acid use. Methods A meta-analysis was conducted to identify relevant randomized controlled trials involving TXA plus a tourniquet (TXA-T group) and use of TXA plus no tourniquet (TXA-NT group) in TKA. Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database were searched from 2010 through October 2021. Results We identified 1720 TKAs (1690 patients) assessed in 14 randomized controlled trials. Compared with the TXA-NT group, the TXA-T group resulted in less intra-operative blood loss (P < 0.00001) and decreased duration of surgery (P < 0.00001), however more hidden blood loss (P = 0.0004) and less knee range of motion (P < 0.00001). No significant differences were found between two groups in terms of decrease in hemoglobin (P = 0.84), total blood loss (P = 0.79), transfusion rate (P = 0.18), drainage volume (P = 0.06), Visual Analogue Scale (VAS) at either the day of surgery (P = 0.2), 1 day (P = 0.25), 2 day (P = 0.39), 3 day (P = 0.21), 5 day (P = 0.21), 7 day (P = 0.06) or 1 month after surgery (P = 0.16), Hospital for Special Surgery (HSS) score at either 7 day (P = 0.10), 1 month (P = 0.08), 3 month (P = 0.22) or 6 month after the surgery (P = 0.92), Knee circumference (P = 0.28), length of hospital (P = 0.12), and complications such as intramuscular venous thrombosis (P = 0.81), deep venous thrombosis (P = 0.10), superficial infection (P = 0.45), deep wound infection (P = 0.64), and delayed wound healing (P = 0.65). Conclusion No big differences could be found by using or not tourniquet when use the TXA, though some benefits are related to operation time and less intra-operative blood loss by using tourniquet and TXA, Using the tourniquet was related to more hidden blood loss and less knee range of motion. More adequately powered and better-designed randomized controlled trials (RCTs) studies with long-term follow-up are required to validate this study.
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Affiliation(s)
- Changjiao Sun
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Xiaofei Zhang
- Department of Clinical Epidemiology and Biostatistics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No.1 68 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Qi Ma
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Yan Tu
- Department of Nursing, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine,, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Xu Cai
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China.
| | - Yonggang Zhou
- Department of Orthopaedic Surgery, The First Medical Centre, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
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Figueroa D. In TKA, Lower Versus Higher Tourniquet Inflation Pressures Reduced Postoperative Pain at the Tourniquet Inflation Site and Surgical Site at 24 and 48 Hours and 2 Weeks. J Bone Joint Surg Am 2021; 103:2143. [PMID: 34546982 DOI: 10.2106/jbjs.21.01008] [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: 02/01/2023]
Affiliation(s)
- David Figueroa
- Facultad de Medicina Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
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Yao S, Zhang W, Ma J, Wang J. Effect of tourniquet application on cement penetration in primary total knee arthroplasty: a meta-analysis. ARTHROPLASTY 2021; 3:29. [PMID: 35236479 PMCID: PMC8796394 DOI: 10.1186/s42836-021-00083-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/16/2021] [Indexed: 11/27/2022] Open
Abstract
Background Tourniquet application is expected to improve surgery exposure and cementation process in total knee arthroplasty (TKA) but its effectiveness remains controversial and needs to be further explored. The aim of this meta-analysis was to assess the effect of tourniquet in primary TKA. The hypothesis is that the tourniquet application affects the cement penetration in TKA. Methods A search was conducted in PubMed, Embase, and the Cochrane Library for the potentially eligible articles. Two independent researchers reviewed the articles retrieved against the pre-designed inclusion and exclusion criteria. In primary TKA, cement penetration was assessed, and the data between the tourniquet-assisted and non-tourniquet-assisted TKAs were compared. Statistical significance was set at P < 0.05. Results A total of 4 randomized controlled trials and 3 non-randomized controlled trials (involving 675 patients) were included. There was no significant difference between the tourniquet-assisted and non-tourniquet-assisted TKAs in terms of cement penetration (P > 0.05). There were no significant differences in the total surgical time, blood loss, blood transfusion, the Knee Society Score, and the visual analogue scale (VAS) between the two kinds of procedures (P > 0.05). Conclusions Tourniquet application may not affect cement penetration in primary TKA and may not help reduce blood loss, ease knee pain or improve the knee function. A surgeon may choose to use a tourniquet or not according to his or her own preference. Level of Evidence Level Ib, meta-analysis.
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Affiliation(s)
- Shuxin Yao
- Department of Orthopedics Honghui Hospital, Xi'An Jiaotong University , No.555 East Youyi Road, Shanxi, Xi'an, China
| | - Weijie Zhang
- Department of Orthopedics Honghui Hospital, Xi'An Jiaotong University , No.555 East Youyi Road, Shanxi, Xi'an, China
| | - Jianbing Ma
- Department of Orthopedics Honghui Hospital, Xi'An Jiaotong University , No.555 East Youyi Road, Shanxi, Xi'an, China
| | - Jianpeng Wang
- Department of Orthopedics Honghui Hospital, Xi'An Jiaotong University , No.555 East Youyi Road, Shanxi, Xi'an, China.
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Zak SG, Yeroushalmi D, Long WJ, Meftah M, Schnaser E, Schwarzkopf R. Does the Use of a Tourniquet Influence Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial. J Arthroplasty 2021; 36:2492-2496. [PMID: 33795174 DOI: 10.1016/j.arth.2021.02.068] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Intraoperative tourniquet use in total knee arthroplasty (TKA) is a common practice which may improve visualization of the surgical field and reduce blood loss. However, the safety and efficacy associated with tourniquet use continues to be a subject of debate among orthopedic surgeons. The primary purpose of this study is to evaluate the effects of tourniquet use on pain and opioid consumption after TKA. METHODS This is a multicenter randomized controlled trial among patients undergoing TKA. Patients were preoperatively randomized to undergo TKA with or without the use of an intraoperative tourniquet. Frequency distributions, means, and standard deviations were used to describe baseline patient demographics (age, gender, race, body mass index, smoking status), length of stay, surgical factors, visual analog scale pain scores, and opioid consumption in morphine milligram equivalents. RESULTS A total of 327 patients were included in this study, with 166 patients undergoing TKA without a tourniquet and 161 patients with a tourniquet. A statistically significant difference was found in surgical time (97.87 vs 92.98 minutes; P = .05), whereas none was found for length of stay (1.73 vs 1.70 days; P = .87), postop visual analog scale pain scores (1.73 vs 1.70; P = .87), inpatient opioid consumption (19.84 vs 19.27 morphine milligram equivalents; P = .74), or outpatient opioid consumption between the tourniquet-less and tourniquet cohorts, respectively. There were no readmissions in either cohort during the 90-day episode of care. CONCLUSION Utilization of a tourniquet during TKA has minimal impact on postoperative pain scores and opioid consumption when compared with patients who underwent TKA without a tourniquet.
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Affiliation(s)
- Stephen G Zak
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery - Adult Joint Reconstruction, NYU Langone Health, New York, NY
| | - David Yeroushalmi
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery - Adult Joint Reconstruction, NYU Langone Health, New York, NY
| | - William J Long
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery - Adult Joint Reconstruction, NYU Langone Health, New York, NY
| | - Morteza Meftah
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery - Adult Joint Reconstruction, NYU Langone Health, New York, NY
| | | | - Ran Schwarzkopf
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery - Adult Joint Reconstruction, NYU Langone Health, New York, NY
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Pinsornsak P, Pinitchanon P, Boontanapibul K. Effect of Different Tourniquet Pressure on Postoperative Pain and Complications After Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial. J Arthroplasty 2021; 36:1638-1644. [PMID: 33509602 DOI: 10.1016/j.arth.2020.12.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/17/2020] [Accepted: 12/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Tourniquet pressure inflation is commonly selected between 100 and 150 mm Hg above the systolic blood pressure (SBP). Given the lack of evidence to support a given inflation pressure, our study aimed to ascertain the lowest tourniquet pressure that facilitated total knee arthroplasty (TKA) and resulted in the least postoperative pain and complications. METHODS In a double-blind, randomized controlled trial of patients scheduled for unilateral primary TKA, 150 were assigned to use tourniquet pressures of SBP + 75 mm Hg (group I), SBP + 100 mm Hg (group II), and SBP + 150 mm Hg (group III). The quality of the bloodless field, total blood loss, and limb swelling were determined perioperatively. Clinical outcomes were evaluated by visual analog scale for pain at thigh and surgical site, serum creatinine phosphokinase levels, wound complications, range of motion, and Knee Society Score. RESULTS Visual analog scale for pain at thigh and surgical site were lowest in group I (P < .01) and highest in group III (P < .01). However, the quality of bloodless field at the tibial cutting surface was significantly better in group III compared to group I/II but not at the femoral cutting surface. The total blood loss and limb swelling showed no difference among 3 groups. Postoperative serum creatinine phosphokinase levels at 24 and 48 hours and wound complications in group III were significantly higher than group I (P < .01) and group II (P < .01). Nevertheless, postoperative knee range of motion and Knee Society Score were not significantly different among 3 groups. CONCLUSION Post TKA, the lowest tourniquet pressure was associated with significantly less postoperative tourniquet and surgical site pain, muscle damage, and wound complications.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, Pathum Thani, Bangkok, Thailand
| | - Punnawit Pinitchanon
- Department of Orthopaedic Surgery, Thammasat University, Pathum Thani, Bangkok, Thailand
| | - Krit Boontanapibul
- Department of Orthopaedic Surgery, Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Bangkok, Thailand
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21
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Woelber E, Wurster L, Brandt S, Mecum P, Gundle K, Anissian L. Minimizing Opioids After Joint Operation: Protocol to Decrease Postoperative Opioid Use After Primary Total Knee Arthroplasty. Fed Pract 2021; 38:e1-e7. [PMID: 33716488 DOI: 10.12788/fp.0092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background For decades, opioids have been the mainstay in pain management after total joint arthroplasty despite evidence that their use should be curtailed. To limit unnecessary prescribing of opioids, the US Department of Veterans Affairs (VA) Portland Health Care System Total Joints Service implemented the Minimizing Opioids After Joint Operation (MOJO) postoperative pain protocol in 2018 to reduce opioid use following total knee arthroplasty (TKA). This protocol included reductions of inpatient and outpatient opioid prescribing, preoperative optimization, use of perioperative nerve blocks, and surgery without a tourniquet. Methods We performed a retrospective chart review that compared the first 20 consecutive patients undergoing TKA using the MOJO protocol with the last 20 patients using the prior routine. Outcomes included total inpatient opioid use, daily opioid use, emergency department (ED) visits or readmissions within 90 days, phone calls for pain or medication refills, length of stay (LOS), and pain during inpatient hospital stay. Results There were significant differences between the pre-MOJO and the MOJO groups with regard to daily inpatient morphine equivalent dose (MED) (82 mg vs 31 mg, P < .01) and total inpatient MEDs (306 mg vs 33 mg, P < .01). There was less self-reported pain on postoperative day 1 in the MOJO group (5.5 vs 4.1, P = .01), decreased LOS (4.4 days vs 1.1 days, P < .01), fewer total ED visits (6 vs 2, P < .07), and fewer discharges to skilled nursing facilities (12 vs 0, P < .01). Conclusions The MOJO protocol reduced postoperative opioid use after TKA in the VA setting without compromising pain control or increasing ED visits. The framework and routines described are potentially applicable to other institutions and surgical specialties.
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Affiliation(s)
- Erik Woelber
- and are Physician Assistants, is a Family Nurse Practitioner, and are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland
| | - Lindsey Wurster
- and are Physician Assistants, is a Family Nurse Practitioner, and are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland
| | - Sarah Brandt
- and are Physician Assistants, is a Family Nurse Practitioner, and are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland
| | - Patricia Mecum
- and are Physician Assistants, is a Family Nurse Practitioner, and are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland
| | - Kenneth Gundle
- and are Physician Assistants, is a Family Nurse Practitioner, and are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland
| | - Lucas Anissian
- and are Physician Assistants, is a Family Nurse Practitioner, and are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland
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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: 2.0] [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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Lu C, Song M, Chen J, Li C, Lin W, Ye G, Wu G, Li A, Cai Y, Wu H, Liu W, Xu X. Does tourniquet use affect the periprosthetic bone cement penetration in total knee arthroplasty? A meta-analysis. J Orthop Surg Res 2020; 15:602. [PMID: 33308270 PMCID: PMC7730759 DOI: 10.1186/s13018-020-02106-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 11/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A tourniquet is a device commonly used to control massive hemorrhage during knee replacement surgery. However, the question remains whether the use of tourniquets affects the permeability of the bone cement around the knee prosthesis. Moreover, the long-term effects and stability of the knee prosthesis are still debatable. The aim of this study was to examine whether the use of a tourniquet increases the thickness of the cement mantle and affects the postoperative blood loss and pain during primary total knee arthroplasty (TKA) using meta-analysis. METHODS We searched the Cochrane Central Library, MEDLINE, Embase, PubMed, CNKI, and Wang Fang databases for randomized controlled trials (RCTs) on primary TKA, from inception to November 2019. All RCTs in primary TKA with and without a tourniquet were included. The meta-analysis was conducted using RevMan 5.2 software. RESULTS A total of eight RCTs (677 knees) were analyzed. We found no significant difference in the age and sex of the patients. The results showed that the application of tourniquet affects the thickness of the bone cement around the tibial prosthesis (WMD = 0.16, 95%CI = 0.11 to 0.21, p < 0.00001). However, in our study, there was no significant difference in postoperative blood loss between the two groups was observed (WMD = 12.07, 95%CI = - 78.63 to 102.77, p = 0.79). The use of an intraoperative tourniquet can increase the intensity of postoperative pain (WMD = 1.34, 95%, CI = 0.32 to 2.36, p = 0.01). CONCLUSIONS Tourniquet application increases the thickness of the bone cement around the prosthesis and may thus increase the stability and durability of the prosthesis after TKA. The application of an intraoperative tourniquet can increase the intensity of postoperative pain.
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Affiliation(s)
- Chao Lu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China
| | - Min Song
- Fifth Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, 510095, Guangdong, China
| | - Jin Chen
- Fifth Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, 510095, Guangdong, China
| | - Congcong Li
- Fifth Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, 510095, Guangdong, China
| | - Wenzheng Lin
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China
| | - Guozhu Ye
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China
| | - Gaoyi Wu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China
| | - Anan Li
- Fifth Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, 510095, Guangdong, China
| | - Yuning Cai
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China
| | - Huai Wu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China
| | - Wengang Liu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China.
| | - Xuemeng Xu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital, NO.60 Hengfu road, Guangzhou, 510095, Guangdong, China.
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Abstract
BACKGROUND The purpose of this study is to evaluate the use of the tourniquet and its effect on post-operative pain in the paediatric population following lower leg procedures. METHODS A retrospective study of paediatric patients (under the age of 18) undergoing inpatient orthopaedic procedure below the knee performed at a single academic institution between 1st December 2013 and 31st January 2019 was conducted. Primary outcome measures of total opioid consumption during hospital stay and pre-operative nerve block utilization were retrieved from the electronic medical record (EMR). Secondary outcome measures of blood loss, tourniquet time, procedure time and length of hospital stay were also retrieved. Student's t-tests were used to assess statistical significance between two sample means. RESULTS The final analysis included 204 paediatric procedures, 118 of which used a tourniquet and 86 of which did not. Paediatric patients with a tourniquet had significantly more opioid consumption post-operatively in the form of weight-based morphine equivalents/length of stay (p = 0.01) compared to those who had no tourniquet. This held true for males (p = 0.049) and females (p = 0.04) respectively. We did not see an increase in wound complications or return trips to the operating room in the tourniquet cohort. All procedures included an osseous component except one procedure in the non-tourniquet group. CONCLUSION Minimizing opioid consumption may be achieved by avoiding tourniquet use in paediatric patients with lower leg procedures. In non-anaemic paediatric patients, it is reasonably risk-free to perform these surgeries without the use of tourniquet to decrease opioid dependence in the post-operative period. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Rewais B. Hanna
- University of Wisconsin Departments of Orthopedics & Rehabilitation, Madison, Wisconsin, USA,Correspondence should be sent to Matthew A. Halanski, Children’s Hospital, 8200 Dodge St, Omaha, NE 68114, USA. E-mail:
| | - Matthew Nies
- University of Wisconsin Departments of Orthopedics & Rehabilitation, Madison, Wisconsin, USA
| | - Pamela J. Lang
- University of Wisconsin Departments of Orthopedics & Rehabilitation, Madison, Wisconsin, USA
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Choudhary A, Kanodia N, Agrawal S, Bhasin VB, Singh A. Tourniquet Use in Arthroscopic ACL Reconstruction: A Blinded Randomized Trial. Indian J Orthop 2020; 55:384-391. [PMID: 33927817 PMCID: PMC8046876 DOI: 10.1007/s43465-020-00250-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/02/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Despite knowing, that tourniquet induces ischemia and soft tissue damage surgeons still use it. The purpose of this study is to compare post operative pain and quadriceps function in patients undergoing arthroscopy assisted ACL reconstruction with tourniquet and without tourniquet. METHODS A blinded randomized prospective trial conducted at Orthopaedic department of a tertiary institute in India from Feb 2019 to June 2019. 45 patients undergoing Arthroscopic ACL reconstruction aged between 18 and 60 years were recruited in the study according to selection criteria. Patients were distributed in 2 groups randomly, namely, tourniquet and non-tourniquet. Preoperatively serum CPK measurement and thigh girth measurement was done. Following standard arthroscopic procedure VAS score monitoring for pain was done for 5 days. Serum CPK levels were performed on postoperative day 1. Thigh girth was measured on postoperative day 21. RESULT Pain was significantly high in patients in whom tourniquet was used. VAS scores were significantly high in tourniquet group. Tourniquet group patients required more amount of additional analgesics in postoperative period (p < 0.001). Serum CPK levels were comparable preoperatively while significantly high postoperatively in tourniquet group (p < 0.001). Difference in mean of thigh girth was significant between the groups (p < 0.001) and there is difficulty experienced by patients in performing straight leg raise test after tourniquet use (p = 0.002). CONCLUSION Tourniquet use is associated with increased pain, analgesic requirement, damage to muscles and compromises muscle function in early postoperative period. This can not only lead to increased patient discomfort but also difficult initial rehabilitation. Arthroscopic procedures can be uneventfully performed without the use of a tourniquet, and alternative methods should be looked upon and emphasized.
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Affiliation(s)
- Abhay Choudhary
- Department of Orthopaedics, Sir Ganga Ram Hospital, Room no: 1218-A 2nd floor, Old Building, Rajinder Nagar, New Delhi, 110060 India
| | - Naman Kanodia
- Department of Orthopaedics, Sir Ganga Ram Hospital, Room no: 1218-A 2nd floor, Old Building, Rajinder Nagar, New Delhi, 110060 India
| | - Siddharth Agrawal
- Department of Orthopaedics, Sir Ganga Ram Hospital, Room no: 1218-A 2nd floor, Old Building, Rajinder Nagar, New Delhi, 110060 India
| | - V. B. Bhasin
- Department of Orthopaedics, Sir Ganga Ram Hospital, Room no: 1218-A 2nd floor, Old Building, Rajinder Nagar, New Delhi, 110060 India
| | - Amarjeet Singh
- Department of Orthopaedics, Sir Ganga Ram Hospital, Room no: 1218-A 2nd floor, Old Building, Rajinder Nagar, New Delhi, 110060 India
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Kasem SA, Bassiouny AAE, Rashwan DAE, Bahr MH. Minimal Inflation Tourniquet Pressure Using Induced Hypotension with Limb Occlusion Pressure Determination or Arterial Occlusion Pressure Estimation in Upper Limb Surgery: A Randomized Double-Blinded Comparative Study. Anesth Pain Med 2020; 10:e102124. [PMID: 32754434 PMCID: PMC7353217 DOI: 10.5812/aapm.102124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/14/2020] [Accepted: 04/19/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives This study compared the efficacy and safety of minimal tourniquet pressure using either determined limb occlusion pressure (LOP) or estimated arterial occlusion pressure (AOP) for elective upper limb surgeries. Methods Forty patients undergone elective upper limb surgery under general hypotensive anesthesia were randomized into groups A and B, where tourniquet pressure was calculated using AOP estimation for group A and LOP determination for group B. AOP, LOP, the time needed to estimate the AOP and determine the LOP and set the tourniquet inflation pressure, tourniquet inflation pressure, initial and maximal systolic blood pressure, heart rate, intraoperative fentanyl requirement, arm circumference, and tourniquet time were recorded. Tourniquet performance was assessed, and signs of tourniquet-related complications were noticed. Results Systolic arterial blood pressure was comparable between the groups. Less time was recorded for measuring AOP or LOP and set the minimal inflation pressure (in second) in group A than in group B (62 ± 2 for group A vs. 120 ± 3 for group B; P < 0.001). The estimated AOP in group A was significantly higher than the determined LOP in group B (118 ± 2 vs. 91 ± 2; P < 0.001). Tourniquet inflation pressures were not significantly different between the groups. Tourniquet performance was excellent or good in all patients in both groups. Conclusions Arterial occlusion pressure estimation or LOP determination methods to set the tourniquet inflation pressure with hypotensive anesthesia can provide effective minimal inflation pressure and satisfactory surgical field for upper extremity surgeries without tourniquet-related complications.
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Affiliation(s)
- Samaa A. Kasem
- Department of Anesthesia Surgical Intensive Care and Pain Managment, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
- Corresponding Author: Assistant Professor of Anesthesia, Faculty of Medicine, Beni-Suef University, Postal Code: 62511, Beni-Suef, Egypt. Tel: +20-822318605,
| | | | - Doaa Abu Elkassim Rashwan
- Department of Anesthesia Surgical Intensive Care and Pain Managment, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Mahmoud Hussein Bahr
- Department of Anesthesia Surgical Intensive Care and Pain Managment, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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Dincel YM, Sarı A, Çetin MÜ, Günaydın B, Agca E, Dogan AH, Varol R. The Effect of Tranexamic Acid and Tourniquet Use on Tibial Cement Penetration in Primary Total Knee Arthroplasties. Arthroplast Today 2020; 6:422-426. [PMID: 32613048 PMCID: PMC7316986 DOI: 10.1016/j.artd.2020.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Yaşar Mahsut Dincel
- Department of Orthopedics and Traumatology, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey
| | - Abdulkadir Sarı
- Department of Orthopedics and Traumatology, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey
| | - Mehmet Ümit Çetin
- Department of Orthopedics and Traumatology, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey
| | - Burak Günaydın
- Department of Orthopedics and Traumatology, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey
| | - Emre Agca
- Department of Orthopedics and Traumatology, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey
| | - Abdullah Heysem Dogan
- Department of Orthopedics and Traumatology, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey
| | - Rüstem Varol
- Department of Orthopedics and Traumatology, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey
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Liu Y, Si H, Zeng Y, Li M, Xie H, Shen B. More pain and slower functional recovery when a tourniquet is used during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:1842-1860. [PMID: 31289914 DOI: 10.1007/s00167-019-05617-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/01/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Although a tourniquet can effectively control intraoperative blood loss and offer clear surgical field in total knee arthroplasty (TKA), its optimal usage has been controversial. The aim of this research was to perform a systematic review and meta-analysis to compare and explore the best application of a tourniquet in TKA. METHODS MEDLINE, PubMed, EMBASE, the Cochrane Library, Wanfang database, and Web of Science were searched for randomized controlled trials (RCTs) comparing the four different strategies of tourniquet application in TKA. In Group I, a tourniquet was not used and was called the non-tourniquet (NT) group. In Group II, a tourniquet was only used during the cementation of implants and was called the specific duration tourniquet (SDT) group. In Group III, the tourniquet was only released before wound closure to control the bleeding sources and was called the majority duration tourniquet (MDT) group. In Group IV, a tourniquet was used throughout the procedure, from skin incision to wound closure and was called the whole duration tourniquet (WDT) group. RESULTS Forty-six RCTs were included in this systematic review and meta-analysis. In a comparison between the NT and WDT groups (25 RCTs), intraoperative blood loss (IBL) (P = 0.0001) and range of motion (ROM) (P = 0.0001) were significantly increased in the NT group, while the visual analog score (VAS) (P = 0.0001), rate of deep vein thrombosis (DVT) (P = 0.01), and all complications (AC) (P = 0.0001) were significantly decreased in the NT group. In a comparison between the SDT and WDT groups (10 RCTs), IBL (P = 0.0001), TBL (P = 0.009), and ROM (P = 0.0001) were significantly increased in the SDT group, while thigh pain (P = 0.04) and the rate of DVT (P = 0.03) were significantly decreased in the SDT group. There were no significant differences between the MDT and WDT groups (12 RCTs) except for the rate of all complications (P = 0.01). CONCLUSION Despite the decrease in IBL with a tourniquet, no difference was found in TBL. In conclusion, not using a tourniquet or only using it during the cementation of implants was preferable based on the faster functional recovery, lower rate of DVTs and complications compared with using a tourniquet throughout the TKA procedure. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Yuan Liu
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Haibo Si
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yi Zeng
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Mingyang Li
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Huiqi Xie
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Bin Shen
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China.
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Jensen J, Hicks RW, Labovitz J. Understanding and Optimizing Tourniquet Use During Extremity Surgery. AORN J 2020; 109:171-182. [PMID: 30694553 DOI: 10.1002/aorn.12579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tourniquet use during extremity surgery is commonplace and a relatively safe practice. The surgical team's knowledge of the patient history, proper assessment, and indications and contraindications for and risks of tourniquet use can prevent unwanted outcomes. Exploration of these critical areas reinforces perioperative nurses' awareness and understanding of safe tourniquet use. Additionally, a review of the physiological effect of tourniquets on the skin, the body's response to local compression, the risk of vascular compromise, and the effect of the tourniquet on postoperative pain and swelling provides insight into AORN recommended practice guidelines. This article summarizes the indications and assessments for and risks of tourniquet use for patients during extremity surgery. An understanding of these topics can improve surgical outcomes and promote safe perioperative care.
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Abstract
Total knee arthroplasty (TKA) has been associated with notable improvements in health-related quality of life of patients with end-stage knee arthritis. Although most patients experience substantial symptomatic relief after TKA, up to 19% of patients are unsatisfied with their outcome. With the dramatic, projected increase in the number of TKAs performed annually, it is crucial to appreciate the various modes of failure associated with this procedure. A comprehensive understanding of the symptomatology and thorough clinical examination aid in identifying the etiology of ongoing knee pain. Ancillary testing including conventional laboratory analyses, imaging studies, and diagnostic injections supplement a thorough history and physical examination. In addition, novel laboratory markers, RNA/DNA-based tests, and novel imaging modalities are emerging as beneficial tools in evaluating patients with a painful TKA. A well-structured, algorithmic approach in the management of these patients is essential in correctly diagnosing the patient and optimizing clinical outcomes.
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Crabtree NE, Mochal-King CA, Sloan PB, Eddy AL, Wills RW, Meredith AN, Fontenot RL. Synovial butorphanol concentrations and mechanical nociceptive thresholds after intravenous regional limb perfusion in standing sedated horses. Vet Surg 2019; 48:1473-1482. [PMID: 31513300 DOI: 10.1111/vsu.13309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/05/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine synovial butorphanol concentrations and mechanical nociceptive threshold (MNT) changes after butorphanol intravenous regional limb perfusion (IVRLP). STUDY DESIGN Experimental ANIMALS: Six adult horses. METHODS Cephalic IVRLP was performed with 10 mg butorphanol in sedated horses with a wide rubber tourniquet and a total volume of 30 mL. Radiocarpal synovial fluid and serum concentrations along with MNT were evaluated prior to and 0.5, 1, 2, 4, and 6 hours after IVRLP. Butorphanol concentrations were determined with liquid chromatography coupled to tandem mass spectrometry positive electrospray ionization. RESULTS Butorphanol concentrations reached mean (SD) peak concentrations of 9.47 ng/mL (±12.00) in synovial fluid and 3.89 ng/mL (3.29) in serum 30 minutes after IVRLP. Concentrations remained above baseline for 4 hours in synovial fluid (P ≤ .017) and for 2 hours in serum (P ≤ .016). The only difference in MNT was detected 1 hour after IVRLP, when MNT were higher in controls than in treated horses (P = .047). CONCLUSION Butorphanol IVRLP seemed well tolerated and resulted in measurable levels of butorphanol in the radiocarpal synovial fluid of five of six horses. CLINICAL SIGNIFICANCE Intravenous regional limb perfusion appears to be a viable alternative to administer butorphanol, but additional investigation is required to evaluate the dose and local concentrations required for analgesia.
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Affiliation(s)
- Naomi E Crabtree
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Cathleen A Mochal-King
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Pearce B Sloan
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Alison L Eddy
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Robert W Wills
- Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Ashley N Meredith
- Mississippi State Chemical Laboratory, Mississippi State University, Mississippi State, Mississippi
| | - Robin L Fontenot
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
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Lyngeraa TS, Jæger P, Gottschau B, Graungaard B, Rossen‐Jørgensen AM, Toftegaard I, Grevstad U. Comparison of the analgesic effect of an adductor canal block using a new suture‐method catheter vs. standard perineural catheter vs. single‐injection: a randomised, blinded, controlled study. Anaesthesia 2019; 74:1397-1405. [DOI: 10.1111/anae.14814] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 11/30/2022]
Affiliation(s)
- T. S. Lyngeraa
- Department of Anaesthesia and Intensive Care Medicine Copenhagen University Hospital Nordsjællands Hospital Hillerød Denmark
| | - P. Jæger
- Department of Anaesthesia, Centre of Head and Orthopaedics Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - B. Gottschau
- Department of Anaesthesia and Intensive Care Medicine Copenhagen University Hospital Gentofte Hospital Gentofte Denmark
| | - B. Graungaard
- Department of Anaesthesia and Intensive Care Medicine Copenhagen University Hospital Gentofte Hospital Gentofte Denmark
| | - A. M. Rossen‐Jørgensen
- Department of Anaesthesia and Intensive Care Medicine Copenhagen University Hospital Gentofte Hospital Gentofte Denmark
| | - I. Toftegaard
- Department of Anaesthesia and Intensive Care Medicine Copenhagen University Hospital Gentofte Hospital Gentofte Denmark
| | - U. Grevstad
- Department of Anaesthesia and Intensive Care Medicine Copenhagen University Hospital Gentofte Hospital Gentofte Denmark
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Kim TK, Bamne AB, Sim JA, Park JH, Na YG. Is lower tourniquet pressure during total knee arthroplasty effective? A prospective randomized controlled trial. BMC Musculoskelet Disord 2019; 20:275. [PMID: 31159799 PMCID: PMC6547572 DOI: 10.1186/s12891-019-2636-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 05/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Higher tourniquet pressures may be associated with an increased risk of complications. We aimed to determine (1) whether a lower tourniquet pressure [systolic blood pressure (SBP) + 120 mmHg] is as effective as conventional tourniquet pressure (SBP + 150 mmHg) in providing a bloodless surgical field and decreasing blood loss, and (2) whether lowering the tourniquet pressure decreases tourniquet-related complications compared to conventional inflation pressure. METHODS One hundred and sixty knees in 124 patients undergoing total knee arthroplasty (TKA) were randomly allocated to either conventional (n = 80) or lower inflation pressure group (n = 80). The quality of the initial surgical field and occurrence of intraoperative blood oozing, hemoglobin drop, drained volume and calculated blood loss were assessed as efficacy variables. Safety outcome variables included post-operative pain, tourniquet site skin problems (ecchymosis, bullae, skin necrosis), and other tourniquet-related complications such as nerve palsy, venous thromboembolism, and delayed rehabilitation. RESULTS A comparable bloodless surgical field was successfully provided in both groups (100% vs. 99%, p = 1.000). One case in the conventional pressure group and two cases in the lower pressure group showed intraoperative blood oozing (p = 1.000), which was successfully controlled after an increase of 30 mmHg in the tourniquet inflation pressure. There was no difference in the hemoglobin drop, drained volume, and calculated blood loss. The two groups did not differ in any safety outcomes such as post-operative pain, thigh complications, and other tourniquet related complications. CONCLUSION This study demonstrates that a tourniquet inflation pressure of 120 mmHg above the SBP is effective method during TKA. TRIAL REGISTRATION The trial was with ClinicalTrials.gov ( NCT01993758 ) on November 25, 2013.
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Affiliation(s)
- Tae Kyun Kim
- TK Orthopedic Surgery, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ankur B Bamne
- Pioneer Hospital, New Panvel, Navi Mumbai, Maharashtra, India
| | - Jae Ang Sim
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Ji Hyeon Park
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Young Gon Na
- Department of Orthopedic Surgery, CM Hospital, 13, Yeongdeungpo-ro 36-gil, Yeongdeungpo-gu, Seoul, 07301, Republic of Korea. .,Former affiliation: Gachon University Gil Medical Center, Incheon, Republic of Korea.
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Ultrasound-guided single injection versus continuous sciatic nerve blockade on pain management and mobilisation after total knee arthroplasty (CoSinUS trial): A randomised, triple-blinded controlled trial. Eur J Anaesthesiol 2019; 35:782-791. [PMID: 29794563 DOI: 10.1097/eja.0000000000000830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combining continuous femoral nerve blockade with single injection sciatic nerve blockade is standard peripheral nerve block practice for total knee arthroplasty (TKA) during the first 24 postoperative hours. OBJECTIVES To assess the analgesic benefits and mobilisation capability of continuous sciatic blockade in conjunction with continuous femoral nerve blockade for 72 h after arthroplasty. DESIGN Randomised, triple-blinded controlled trial. SETTING Single-Centre, German University Hospital. PATIENTS In total, 50 patients receiving continuous femoral nerve blockade (5 ml h ropivacaine 0.2%) for TKA under general anaesthesia. INTERVENTIONS Patients were randomised to receive a sciatic nerve catheter with an initial dose of 10 ml ropivacaine 0.2% followed by either continuous double-blinded application of 5 ml h ropivacaine 0.2% (CO) or 5 ml h saline infusion (SIN). MAIN OUTCOME Measures primary endpoint: cumulative morphine consumption until 48 h postoperatively. Further endpoints included morphine consumption, pain scores, mobilisation, dynamometry until postoperative day 3. RESULTS Median [25th to 75th percentiles] cumulative morphine consumption at postoperative day 2 differed significantly between groups (CO 15 mg [11 to 25] versus SIN, 43 mg [27 to 67.5, P < 0.0001) in the 48 patients in the final analysis. Overall pain scores were comparable at rest and during stress at each time point. However, significantly higher pain scores of the popliteal fossa were observed in the SIN group. Mobilisation was comparable between groups. CONCLUSION This trial demonstrates the superior analgesic effects of continuous sciatic nerve block compared with a single injection in combination with continuous femoral blockade during the first 72 h after TKA. However, mobilisation capability was impaired in both groups. Improved pain control from two catheters needs to be balanced against the potential risks of impaired mobilisation and patient falls. TRIAL REGISTRATION DRKS - German clinical trials register (no: DRKS00010152).
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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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Clark BM, Pagani-Estevez GL, Johnson RL. Lidocaine Patch to Treat Postoperative Tourniquet Pain After Total Knee Replacement: A Case Report. A A Pract 2019; 11:173-174. [PMID: 29672324 DOI: 10.1213/xaa.0000000000000772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intraoperative tourniquet-related pain is well recognized by anesthesiologists, but postoperative tourniquet-related pain has received little attention. We present a patient who underwent a total knee arthroplasty under general anesthesia and an adductor canal nerve block. She complained of intractable thigh pain postoperatively. Lidocaine 5% patches completely resolved her postoperative tourniquet-related pain.
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Hasanain MS, Apostu D, Alrefaee A, Tarabichi S. Comparing the Effect of Tourniquet vs Tourniquet-Less in Simultaneous Bilateral Total Knee Arthroplasties. J Arthroplasty 2018; 33:2119-2124. [PMID: 29510953 DOI: 10.1016/j.arth.2018.02.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/01/2018] [Accepted: 02/03/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a commonly performed procedure worldwide for the treatment of knee joint disease. Tourniquet is frequently used during the entire procedure to reduce blood loss and increase surgical comfort. On the other hand, tourniquet-related complications exist, and there are still controversies whether benefits outweigh the risks. METHODS Patients undergoing simultaneous TKAs had one knee assigned to group A (use of tourniquet during the entire procedure) and the other knee assigned to group B (use of tourniquet only during cementation). Blood loss, intraoperative complications, implant alignment, soft tissue swelling, pain score, and range of motion were analyzed. RESULTS Fifty-four patients undergoing 108 TKAs were included in the study. Total blood loss was almost 2 times higher in group B knees compared with group A. No difference was observed between groups in implant alignment, soft tissue swelling, pain, range of motion, or other early postoperative complications. CONCLUSION Tourniquet use in TKAs during the entire surgical procedure reduces total blood loss, without an increase in early postoperative complications.
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Affiliation(s)
| | - Dragos Apostu
- Department of Orthopaedics and Traumatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Attaallh Alrefaee
- Department of Orthopaedics, Burjeel Hospital for Advanced Surgery, Dubai, UAE
| | - Samih Tarabichi
- Department of Orthopaedics, Burjeel Hospital for Advanced Surgery, Dubai, UAE
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Vaishya R, Agarwal AK, Vijay V, Tiwari MK. Short term outcomes of long duration versus short duration tourniquet in primary total knee arthroplasty: A randomized controlled trial. J Clin Orthop Trauma 2018; 9:46-50. [PMID: 29628683 PMCID: PMC5884052 DOI: 10.1016/j.jcot.2017.11.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/27/2017] [Accepted: 11/30/2017] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION A tourniquet is used during the total knee replacement surgery to improve the visibility, to reduce the blood loss and for better cementation. Indirectly it decreases the duration of surgery and enhances the recovery of the patient. Their use however is controversial due to some side effects associated with the use of tourniquet. They may increase the risk of deep vein thrombosis and pulmonary embolism by causing venous stasis, endothelial damage and increased platelet adhesion secondary to distal limb ischemia. MATERIAL AND METHODS We conducted a randomized controlled trial (RCT) to examine the benefits and risks associated with the use of long duration over short duration tourniquets during TKA. The study was a prospective randomised control trial with a total of 80 knees (40 knees in each group) included in the study. The knees selected for surgery were randomly allocated to one of the two groups: Group A - long duration tourniquet (LT-group) or Group B - short duration tourniquet (ST-group). RESULT The average operating time in Group A (43.53±3.11 minutes) was statistically less significant than that of Group B (51.7±2.56 minutes). Intra-operative blood loss in Group B, was significantly more than that of Group A. Post-operative blood loss in the drain was more in long duration tourniquet group. Total blood loss (intra-operative + post-operative) was more in short duration tourniquet group. Pain score (using VAS scale) was comparable in both the groups at the end of the second and sixth week. At sixth weeks there was no significant difference in the range of motion in both the groups. The KSS score was not significantly different in both the groups in post operative period at first, second, and six weeks. There were no events of thrombo-embolism and deep vein thrombosis in either groups. In 11 patients (27.5%) of long duration tourniquet group, swelling, and redness of knee was seen post operatively as compared to three patients (7.5%) of short duration tourniquet group. CONCLUSION The use of a short duration tourniquet during TKA gives better symptomatic pain relief in the early postoperative period as compared to long duration use of tourniquet. However, this is associated with increased blood loss, more operating time and not having a clear operative field. We suggest that a rational thinking and reconsidering the practice of routine use of long duration tourniquet in each and every case of TKA is required.
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Sylvester LN, Goree JH. Genicular Radiofrequency Ablation for Treatment of Post Total Knee Arthroplasty Posterior Thigh Pain. ACTA ACUST UNITED AC 2017; 9:292-293. [DOI: 10.1213/xaa.0000000000000596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Barrington JH, Chrismas BCR, Gibson OR, Tuttle J, Pegrum J, Govilkar S, Kabir C, Giannakakis N, Rayan F, Okasheh Z, Sanaullah A, Ng Man Sun S, Pearce O, Taylor L. Hypoxic Air Inhalation and Ischemia Interventions Both Elicit Preconditioning Which Attenuate Subsequent Cellular Stress In vivo Following Blood Flow Occlusion and Reperfusion. Front Physiol 2017; 8:560. [PMID: 28824456 PMCID: PMC5539087 DOI: 10.3389/fphys.2017.00560] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/18/2017] [Indexed: 12/17/2022] Open
Abstract
Ischemic preconditioning (IPC) is valid technique which elicits reductions in femoral blood flow occlusion mediated reperfusion stress (oxidative stress, Hsp gene transcripts) within the systemic blood circulation and/or skeletal muscle. It is unknown whether systemic hypoxia, evoked by hypoxic preconditioning (HPC) has efficacy in priming the heat shock protein (Hsp) system thus reducing reperfusion stress following blood flow occlusion, in the same manner as IPC. The comparison between IPC and HPC being relevant as a preconditioning strategy prior to orthopedic surgery. In an independent group design, 18 healthy men were exposed to 40 min of (1) passive whole-body HPC (FiO2 = 0.143; no ischemia. N = 6), (2) IPC (FiO2 = 0.209; four bouts of 5 min ischemia and 5 min reperfusion. n = 6), or (3) rest (FiO2 = 0.209; no ischemia. n = 6). The interventions were administered 1 h prior to 30 min of tourniquet derived femoral blood flow occlusion and were followed by 2 h subsequent reperfusion. Systemic blood samples were taken pre- and post-intervention. Systemic blood and gastrocnemius skeletal muscle samples were obtained pre-, 15 min post- (15PoT) and 120 min (120PoT) post-tourniquet deflation. To determine the cellular stress response gastrocnemius and leukocyte Hsp72 mRNA and Hsp32 mRNA gene transcripts were determined by RT-qPCR. The plasma oxidative stress response (protein carbonyl, reduced glutathione/oxidized glutathione ratio) was measured utilizing commercially available kits. In comparison to control, at 15PoT a significant difference in gastrocnemius Hsp72 mRNA was seen in HPC (−1.93-fold; p = 0.007) and IPC (−1.97-fold; p = 0.006). No significant differences were observed in gastrocnemius Hsp32 and Hsp72 mRNA, leukocyte Hsp72 and Hsp32 mRNA, or oxidative stress markers (p > 0.05) between HPC and IPC. HPC provided near identical amelioration of blood flow occlusion mediated gastrocnemius stress response (Hsp72 mRNA), compared to an established IPC protocol. This was seen independent of changes in systemic oxidative stress, which likely explains the absence of change in Hsp32 mRNA transcripts within leukocytes and the gastrocnemius. Both the established IPC and novel HPC interventions facilitate a priming of the skeletal muscle, but not leukocyte, Hsp system prior to femoral blood flow occlusion. This response demonstrates a localized tissue specific adaptation which may ameliorate reperfusion stress.
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Affiliation(s)
- James H Barrington
- Institute of Sport and Physical Activity Research, University of BedfordshireLuton, United Kingdom
| | - Bryna C R Chrismas
- Sport Science Program, College of Arts and Sciences, Qatar UniversityDoha, Qatar
| | - Oliver R Gibson
- Division of Sport, Health and Exercise Sciences, Department of Life Sciences, Centre for Human Performance, Exercise and Rehabilitation, Brunel University LondonUxbridge, United Kingdom
| | - James Tuttle
- Institute of Sport and Physical Activity Research, University of BedfordshireLuton, United Kingdom
| | - J Pegrum
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - S Govilkar
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - Chindu Kabir
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - N Giannakakis
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - F Rayan
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - Z Okasheh
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - A Sanaullah
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - S Ng Man Sun
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - Oliver Pearce
- Milton Keynes University HospitalMilton Keynes, United Kingdom
| | - Lee Taylor
- ASPETAR, Athlete Health and Performance Research Centre, Qatar Orthopedic and Sports Medicine HospitalDoha, Qatar.,School of Sport, Exercise and Health Sciences. Loughborough UniversityLoughborough, United Kingdom
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Torrie A, Sharma J, Mason M, Eng HC. Regional Anesthesia Did Not Delay Diagnosis of Compartment Syndrome: A Case Report of Anterior Compartment Syndrome in the Thigh Not Masked by an Adductor Canal Catheter. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:444-447. [PMID: 28435149 PMCID: PMC5410882 DOI: 10.12659/ajcr.902708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/20/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute compartment syndrome (ACS) of the thigh after elective primary total knee arthroplasty is rare. If not recognized and treated promptly, devastating consequences may result. Certain regional anesthesia techniques are thought to mask the symptoms of acute compartment syndrome, but there are no cases reported of adductor canal catheters masking the symptoms of thigh compartment syndrome. We report a case where symptoms and diagnosis of acute anterior thigh compartment syndrome were not masked by a functioning adductor canal catheter. CASE REPORT A 56-year-old male developed anterior thigh compartment syndrome after an elective primary total knee arthroplasty. Surgery was performed under spinal anesthesia with periarticular local infiltration analgesia. Postoperatively, an adductor canal catheter was placed, atraumatically, under ultrasound guidance in the recovery room with a plan to begin a continuous infusion of 0.2% ropivacaine 10 hours after the periarticular injection. Six hours after surgery, the patient complained of tightness and 10/10 pain in his right thigh, which was initially managed with parenteral opioids with moderate success. Continuous infusion through the adductor canal catheter was started and pain improved to 6/10 aching pain. Nonetheless, two hours after starting the continuous infusion, the patient reported tightness, swelling, and 10/10 pressure-like pain that was not relieved by the peripheral catheter infusion or PRN boluses of additional opioids. Due to the patient's symptomatology compartment pressures were measured. The anterior compartment pressure was 47 mm Hg and emergent anterior compartment fasciotomy was performed. CONCLUSIONS In this case, a functioning adductor canal catheter did not mask symptoms of, or delay diagnosis of, acute compartment syndrome in the thigh.
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Affiliation(s)
- Arissa Torrie
- Department of Internal Medicine, Penn State Health, Hershey, PA, U.S.A
| | - Jyoti Sharma
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, U.S.A
| | - Mark Mason
- Department of Orthopedic Surgery, Penn State Health, Hershey, PA, U.S.A
| | - Hillenn Cruz Eng
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, U.S.A
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Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J. Timing of tourniquet release in total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2017; 96:e6786. [PMID: 28445317 PMCID: PMC5413282 DOI: 10.1097/md.0000000000006786] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/21/2017] [Accepted: 04/07/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For total knee arthroplasty (TKA), the tourniquet is routinely employed for better visualization, less blood loss, and easier cementation. However, the time to release tourniquet remains controversial. Therefore, we performed current meta-analysis to assess whether releasing tourniquet before wound closure is more effective in reducing blood loss than releasing tourniquet after wound closure in TKA without an increased risk of complications. METHODS To conduct this meta-analysis, we searched Medline, Embase, Web of science, and the Cochrane library up to November 2016, for randomized controlled trials comparing tourniquet releasing before and after wound closure in TKA. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Methodological quality of the trials was assessed using the Cochrane risk assessment scale. The data of the included studies were analyzed using Stata 12.0. RESULTS Sixteen trials involving 1010 patients were identified in current meta-analysis. Our meta-analysis demonstrated that there were no significant differences in the 2 groups in terms of calculated blood loss (weighted mean difference [WMD] = 160.65, 95% confidence interval [CI]: -0.2 to 321.49, P = .05), postoperative blood loss (WMD = -45.41, 95% CI: -120.11 to 29.29, P = .233),postoperative hemoglobin decline (WMD = 0.16, 95% CI: -2.5 to 2.82, P = .905), transfusion volume (WMD = 79.19, 95% CI: -5.05 to 163.44, P = .065),transfusion rates (relative risk [RR] = 1.19, 95% CI: 0.95-1.50, P = .134), major complications (RR = 0.51, 95% CI: 0.15-1.73, P = .278), and deep vein thrombosis (RR = 0.44, 95% CI: 0.14-1.37, P = .157).Compared with the group of releasing tourniquet after wound closure, the group of releasing tourniquet before wound closure had a higher volume of total blood loss (WMD = 130.96, 95% CI: 58.83-203.09, P = .000) and a longer operation time (WMD = 6.56, 95% CI: 3.12-10.01, P = .000). However, releasing tourniquet before wound closure could reduce minor complications (RR = 0.53, 95% CI: 0.34-0.82, P = .004). CONCLUSIONS On the basis of current meta-analysis, the method of releasing tourniquet before wound closure could increase total blood loss and operation time; nevertheless, the risk of complications decreased. Thus, if patients are in severe anemia condition, the tourniquet perhaps should be released after wound closure to decrease blood loss. In contrary, releasing tourniquet before wound closure to decrease the risk of complications would be a better choice.
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Affiliation(s)
- Pei Zhang
- Dalian Medical University, Dalian, Liaoning, China
| | - Yuan Liang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Jinshan He
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Yongchao Fang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Pengtao Chen
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Jingcheng Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
- Dalian Medical University, Dalian, Liaoning, China
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Leão MGDS, Martins Neta GP, Coutinho LI, da Silva TM, Ferreira YMC, Dias WRV. Análise comparativa da dor em pacientes submetidos à artroplastia total do joelho em relação aos níveis pressóricos do torniquete pneumático. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2016.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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de Souza Leão MG, Neta GPM, Coutinho LI, da Silva TM, Ferreira YMC, Dias WRV. Comparative analysis of pain in patients who underwent total knee replacement regarding the tourniquet pressure. Rev Bras Ortop 2016; 51:672-679. [PMID: 28050539 PMCID: PMC5198071 DOI: 10.1016/j.rboe.2016.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/10/2016] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To evaluate through the visual analog scale (VAS) the pain in patients undergoing total knee replacement (TKR) with different pressures of the pneumatic tourniquet. METHODS An observational, randomized, descriptive study on an analytical basis, with 60 patients who underwent TKR, divided into two groups, which were matched: a group where TKR was performed with tourniquet pressures of 350 mmHg (standard) and the other with systolic blood pressure plus 100 mmHg (P + 100). These patients had their pain assessed by VAS at 48 h, and at the 5th and 15th days after procedure. Secondarily, the following were also measured: range of motion (ROM), complications, and blood drainage volume in each group; the data were subjected to statistical analysis. RESULTS After data analysis, there was no statistical difference regarding the incidence of complications (p = 0.612), ROM (p = 0.202), bleeding after 24 and 48 h (p = 0.432 and p = 0.254) or in relation to VAS. No correlation was observed between time of ischemia compared to VAS and bleeding. CONCLUSIONS The use of the pneumatic tourniquet pressure at 350 mmHg or systolic blood pressure plus 100 mmHg did not influence the pain, blood loss, ROM, and complications. Therefore the pressures at these levels are safe and do not change the surgery outcomes; the time of ischemia must be closely observed to avoid major complications.
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Pfitzner T, von Roth P, Voerkelius N, Mayr H, Perka C, Hube R. Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24:96-101. [PMID: 25248311 DOI: 10.1007/s00167-014-3341-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/17/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of the study was whether the use of a tourniquet increases cement mantle thickness in primary total knee arthroplasty and influences the calculated blood loss and postoperative pain. METHODS Ninety patients with a primary total knee arthroplasty (TKA) were enroled in this prospective randomised trial and divided into a group with (n = 45) and without tourniquet (n = 45). The radiological tibial cement mantle thickness was evaluated postoperatively in four zones on anteroposterior and two zones on lateral radiographs, and values were cumulated. Additionally, the calculated blood loss and postoperative pain levels were recorded. RESULTS There was a median cumulative cement mantle thickness of 13 mm (range 8-19 mm) without tourniquet and of 14.2 mm (range 9-18 mm) with tourniquet (p = 0.009). The median calculated blood loss was 0.6 L (range 0.2-2.0 L) without and 0.9 L (range 0.3-1.5 L) (p = 0.02) with tourniquet. Patient-reported postoperative pain levels were significantly higher in the tourniquet group during mobilisation (p = 0.01) and at rest (p = 0.001). CONCLUSIONS The use of a tourniquet in primary TKA increased the tibial cement mantle thickness but also increased the postoperative calculated blood loss and postoperative pain. Surgeons might take this into consideration for decision-making whether to use a tourniquet during TKA. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Tilman Pfitzner
- Orthopaedic Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Philipp von Roth
- Orthopaedic Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ninja Voerkelius
- Orthopädische Chirurgie München, Steinerstraße 6, 81369, Munich, Germany
| | - Hermann Mayr
- Orthopädische Chirurgie München, Steinerstraße 6, 81369, Munich, Germany
| | - Carsten Perka
- Orthopaedic Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Robert Hube
- Orthopädische Chirurgie München, Steinerstraße 6, 81369, Munich, Germany
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Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial. Clin Orthop Relat Res 2016; 474:69-77. [PMID: 26100254 PMCID: PMC4686529 DOI: 10.1007/s11999-015-4393-8] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Tourniquet use during total knee arthroplasty (TKA) improves visibility and reduces intraoperative blood loss. However, tourniquet use may also have a negative impact on early recovery of muscle strength and lower extremity function after TKA. QUESTIONS/PURPOSES The purpose of this study was (1) to determine whether tourniquet use affects recovery of quadriceps strength (primary outcome) during the first 3 postoperative months; and (2) to examine the effects of tourniquet application on secondary outcomes: voluntary quadriceps activation, hamstring strength, unilateral limb balance as well as the effect on operative time and blood loss. METHODS Twenty-eight patients (mean age 62 ± 6 years; 16 men) undergoing same-day bilateral TKA (56 lower extremities) were enrolled in a prospective, randomized study. Subjects were randomized to receive a tourniquet-assisted knee arthroplasty on one lower extremity while the contralateral limb underwent knee arthroplasty without extended tourniquet use. In the former group, the tourniquet was inflated just before the incision was made and released after cementation; in the latter group, a tourniquet was not used (10 of 28 [36%]) or inflated only during component cementation (18 of 28 [64%]). The choice of no tourniquet or use just during cementation was based on surgeon choice, because some surgeons felt a tourniquet during cementation was necessary to achieve a dry surgical field to maximize cement fixation. A median parapatellar approach and the identical posterior-stabilized TKA design were used by all four fellowship-trained knee surgeons involved. Isometric quadriceps strength, hamstring strength, voluntary quadriceps activation, and unilateral balance were assessed preoperatively, 3 weeks, and 3 months after bilateral knee arthroplasty. Other factors, including pain, range of motion, and lower extremity girth, were assessed for descriptive purposes at each of these time points as well as on the second postoperative day. RESULTS Quadriceps strength was slightly lower in the tourniquet group compared with the no-tourniquet group (group difference = 11.27 Nm [95% confidence interval {CI}, 2.33-20.20]; p = 0.01), and these differences persisted at 3 months after surgery (group difference = 9.48 Nm [95% CI, 0.43-18.54]; p = 0.03). Hamstring strength did not differ between groups at any time point nor did measures of quadriceps voluntary activation or measures of unilateral balance ability. There was less estimated intraoperative blood loss in the tourniquet group (84 ± 26 mL) than in the no-tourniquet group (156 ± 63 mL) (group difference = -74 mL [95% CI, -100 to -49]; p < 0.001). However, there was no difference in total blood loss between the groups (group difference = -136 mL [95% CI, -318 to 45]; p = 0.13). CONCLUSIONS Patients who underwent TKA using a tourniquet had diminished quadriceps strength during the first 3 months after TKA, the clinical significance of which is unclear. Future studies may be warranted to examine the effects of tourniquet use on long-term strength and functional outcomes. LEVEL OF EVIDENCE Level I, therapeutic study.
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Mutlu S, Guler O, Mutlu H, Karaman O, Duymus TM, Parmaksizoglu AS. Tourniquet use during total knee arthroplasty does not offer significant benefit: A retrospective cohort study. Int J Surg 2015; 18:123-7. [DOI: 10.1016/j.ijsu.2015.04.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/09/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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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: 3.6] [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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Liu D, Graham D, Gillies K, Gillies RM. Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. Knee Surg Relat Res 2014; 26:207-13. [PMID: 25505702 PMCID: PMC4258487 DOI: 10.5792/ksrr.2014.26.4.207] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 07/13/2014] [Accepted: 08/16/2014] [Indexed: 11/05/2022] Open
Abstract
Purpose A pneumatic tourniquet is commonly used in total knee arthroplasty (TKA) to improve surgical field visualisation but may result in quadriceps muscle ischaemia. We performed this study to analyse the effect of the tourniquet on recovery following TKA. Materials and Methods A prospective randomised single-blinded trial was undertaken to examine the effect of the tourniquet on post-operative pain, swelling, blood loss, quadriceps function and outcome following TKA. Twenty patients with osteoarthritis of the knee were randomised to tourniquet or no tourniquet groups. Quadriceps function was assessed using surface electromyography (EMG) during active knee extension. Results The no tourniquet group had significantly less pain in the early post-operative period compared to the tourniquet group. There was no difference in Oxford knee score, range of motion, or thigh and knee swelling up to 12 months post-operatively. Quadriceps function, measured by surface EMG, was compromised for the first six months post-surgery by tourniquet use. The radiological cement mantle at the bone prosthesis interface at 12-month follow-up was not affected by the absence of a tourniquet. Conclusions We believe that it is safe and beneficial for our patients to routinely perform TKA without a tourniquet.
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Affiliation(s)
- David Liu
- Gold Coast Centre for Bone and Joint Surgery, John Flynn Private Hospital, Gold Coast, Australia
| | - David Graham
- Department of Orthopedic Surgery, Gold Coast and Robina Hospitals, Gold Coast, Australia
| | | | - R Mark Gillies
- University of Sydney, Kolling Institute, Murray Maxwell Biomechanics Laboratory, Royal North Shore Hospital, Sydney, Australia
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Ejaz A, Laursen AC, Kappel A, Laursen MB, Jakobsen T, Rasmussen S, Nielsen PT. Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop 2014; 85:422-6. [PMID: 24954487 PMCID: PMC4105775 DOI: 10.3109/17453674.2014.931197] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Tourniquet application is still a common practice in total knee arthroplasty (TKA) surgery despite being associated with several adverse effects. We evaluated the effects of tourniquet use on functional and clinical outcome and on knee range of motion (ROM). PATIENTS AND METHODS 70 patients who underwent TKA were randomized into a tourniquet group (n = 35) and a non-tourniquet group (n = 35). All operations were performed by the same surgeon and follow-up was for 1 year. Primary outcomes were functional and clinical outcomes, as evaluated by KOOS and knee ROM. Secondary outcomes were intraoperative blood loss, surgical time and visibility, postoperative pain, analgesic consumption, and transfusion requirements. RESULTS Patients in the non-tourniquet group showed a better outcome in all KOOS subscores and better early knee ROM from surgery to week 8. No difference was detected at the 6- and 12-month follow-ups. Postoperative pain and analgesic consumption were less when a tourniquet was not used. Surgical time and visibility were similar between groups. Intraoperative blood loss was greater when not using a tourniquet, but no postoperative transfusions were required. INTERPRETATION This study shows that TKA without the use of a tourniquet results in faster recovery in terms of better functional outcome and improved knee ROM. Furthermore, reduced pain and analgesic use were registered and no intraoperative difficulties were encountered.
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Affiliation(s)
- Ashir Ejaz
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Anders C Laursen
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Mogens B Laursen
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Thomas Jakobsen
- Department of Orthopedic Surgery,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Sten Rasmussen
- Department of Orthopedic Surgery,Orthopedic Surgery Research Unit, Aalborg University Hospital,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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