A Randomized Controlled Study on the Use of Tourniquet in Primary Total Knee Arthroplasty

Chaofan Zhang; Chun Hoi Yan; Ping Keung Chan; Henry Fu; Kwong Yuen Chiu

doi:10.1055/s-0041-1740926

The Journal of Knee Surgery, Table of Contents

J Knee Surg 2022; 35(06): 698-706
DOI: 10.1055/s-0041-1740926

Original Article

A Randomized Controlled Study on the Use of Tourniquet in Primary Total Knee Arthroplasty

Chaofan Zhang

¹Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China

²Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China

³Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China

,

Chun Hoi Yan

¹Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China

²Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China

,

Ping Keung Chan

¹Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China

²Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China

,

Henry Fu

¹Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China

²Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China

,

Kwong Yuen Chiu

¹Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China

²Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China

› Author Affiliations

Abstract

Background The use and the optimal timing of tourniquet during primary total knee arthroplasty (TKA) is controversial. Most previous studies failed to show clinically significant differences in different strategies. The aim of this study was to determine how three strategies of tourniquet application affect the outcome in TKA patients.

Methods This was a prospective randomized controlled study. Patients who undergo TKA were randomized into one of the three groups (1:1:1 ratio): tourniquet inflated from skin incision to cement hardening, tourniquet from cement application to hardening, and tourniquet from skin incision to skin closure. The perioperative blood loss, limb swelling, and complications were recorded. The level of hemoglobin, hematocrit, C-reactive protein (CRP), interleukin (IL)-6, creatine kinase (CK), and lactate dehydrogenase (LDH) were determined. Patients' thigh and TKA wound pain, Knee Society knee score (KSKS) and Knee Society functional assessment (KSFA) scores, and rehabilitation parameters were evaluated.

Results A total of 90 patients were enrolled. The baseline characteristics were comparable. We only found significant difference in the intraoperative blood loss (skin to cement: 58.7 ± 36.1 mL, cement-only: 147.8 ± 107.9 mL, skin to skin: 16.3 ± 13.1 mL, p < 0.0001). There were no statistical differences in postoperative drainage, thigh/knee circumference, change of hemoglobin/hematocrit, CRP, IL-6, CK, and LDH on day 1 to day 4 after surgery. The thigh/TKA wound Visual Analogue Scale scores, KSKS score, KSFA score, and rehabilitation parameters were not significantly different at up to 6-month follow-up. No thromboembolic events were noted.

Conclusion Our results revealed that there was no best tourniquet strategy in TKA. Different tourniquet methods can be utilized based on surgeon preference without affecting outcomes.

Keywords

total knee arthroplasty - randomized controlled study - tourniquet - perioperative blood loss - rehabilitation

Full Text

References

References
1 Tai T-W, Chang C-W, Lai K-A, Lin C-J. Yang C-Y. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty. J Bone Jt Surg 2012; 94 (24) 2209-2215
2 Tarwala R, Dorr LD, Gilbert PK, Wan Z, Long WT. Tourniquet use during cementation only during total knee arthroplasty: a randomized trial. Clin Orthop Relat Res 2014; 472 (01) 169-174
3 Dong J, Min S, He KH, Peng LH, Cao J, Ran W. Effects of the nontourniquet combined with controlled hypotension technique on pain and long-term prognosis in elderly patients after total knee arthroplasty: a randomized controlled study. J Anesth 2019; 33 (05) 587-593
4 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 (07) 2119-2124
5 Dennis DA, Kittelson AJ, Yang CC, Miner TM, Kim RH, Stevens-Lapsley JE. Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res 2016; 474 (01) 69-77
6 Ledin H, Aspenberg P, Good L. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthop 2012; 83 (05) 499-503
7 Schulz KF, Altman DG, Moher D. CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med 2010; 152 (11) 726-732
8 Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty? Correct blood loss management should take hidden loss into account. Knee 2000; 7 (03) 151-155
9 Ingemarsson AH, Frändin K, Mellström D, Möller M. Walking ability and activity level after hip fracture in the elderly–a follow-up. J Rehabil Med 2003; 35 (02) 76-83
10 Berg K. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can 1989; 41 (06) 304-311
11 Price AJ, Alvand A, Troelsen A. et al. Knee replacement. Lancet 2018; 392 (10158): 1672-1682
12 Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P. A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty 2012; 27 (03) 331-340
13 Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M. Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res 2000; (371) 169-177
14 Zan PF, Yang Y, Fu D, Yu X, Li GD. Releasing of tourniquet before wound closure or not in total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty 2015; 30 (01) 31-37
15 Arthur JR, Spangehl MJ. Tourniquet use in total knee arthroplasty. J Knee Surg 2019; 32 (08) 719-729
16 Tai T-W, Lin C-J, Jou I-M, Chang C-W, Lai K-A, Yang C-Y. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2011; 19 (07) 1121-1130
17 Cai DF, Fan QH, Zhong HH, Peng S, Song H. The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: a meta-analysis. J Orthop Surg Res 2019; 14 (01) 348
18 Kvederas G, Porvaneckas N, Andrijauskas A. et al. A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2013; 21 (12) 2790-2799
19 Horlocker TT, Hebl JR, Gali B. et al. Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg 2006; 102 (03) 950-955
20 Kumar SN, Chapman JA, Rawlins I. Vascular injuries in total knee arthroplasty. A review of the problem with special reference to the possible effects of the tourniquet. J Arthroplasty 1998; 13 (02) 211-216
21 Palmer SH, Graham G. Tourniquet-induced rhabdomyolysis after total knee replacement. Ann R Coll Surg Engl 1994; 76 (06) 416-417
22 Tamvakopoulos GS, Toms AP, Glasgow M. Subcutaneous thigh fat necrosis as a result of tourniquet control during total knee arthroplasty. Ann R Coll Surg Engl 2005; 87 (05) W11-3
23 Heller S, Chen A, Restrepo C, Albert E, Hozack WJ. Tourniquet release prior to dressing application reduces blistering following total knee arthroplasty. J Arthroplasty 2015; 30 (07) 1207-1210
24 Leurcharusmee P, Sawaddiruk P, Punjasawadwong Y, Chattipakorn N, Chattipakorn SC. The possible pathophysiological outcomes and mechanisms of tourniquet-induced ischemia-reperfusion injury during total knee arthroplasty. Oxid Med Cell Longev 2018; 2018: 8087598
25 Wang K, Ni S, Li Z. et al. The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 2017; 25 (09) 2849-2857