Download PDF
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
1   Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
2   Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
3   Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
,
Chun Hoi Yan
1   Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
2   Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
,
Ping Keung Chan
1   Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
2   Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
,
Henry Fu
1   Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
2   Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
,
Kwong Yuen Chiu
1   Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
2   Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
› Author Affiliations Funding This study was funded by the internal research fund from the Department of Orthopaedics and Traumatology, the University of Hong Kong.
› Further Information
    Permissions and Reprints

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

Ethical Approval

Each author certified that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. The protocol was approved by our institutional review board (HKU/HA HKW IRB number: UW 15 -129). This randomized controlled trial has been registered at clinicaltrials.gov (registration number: NCT04502459).




Publication History

Received: 07 October 2020

Accepted: 16 November 2021

Article published online:
03 January 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 10 Berg K. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can 1989; 41 (06) 304-311
    CrossrefPubMedGoogle Scholar
  • 11 Price AJ, Alvand A, Troelsen A. et al. Knee replacement. Lancet 2018; 392 (10158): 1672-1682
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 15 Arthur JR, Spangehl MJ. Tourniquet use in total knee arthroplasty. J Knee Surg 2019; 32 (08) 719-729
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 21 Palmer SH, Graham G. Tourniquet-induced rhabdomyolysis after total knee replacement. Ann R Coll Surg Engl 1994; 76 (06) 416-417
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar