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Sun ZJ, Chen CH, Tan ZL, Li CR, Fei H, Yu X, Yao DC, Li T. Personalized tourniquet pressure versus uniform tourniquet pressure in orthopedic trauma surgery of extremities: A prospective randomized controlled study protocol. Contemp Clin Trials Commun 2024; 42:101376. [PMID: 39555241 PMCID: PMC11566336 DOI: 10.1016/j.conctc.2024.101376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/28/2024] [Accepted: 09/25/2024] [Indexed: 11/19/2024] Open
Abstract
Background In the field of orthopedic surgery, tourniquets are often used to achieve a clear operative field, expedite operations, and minimize hemorrhagic events. However, determining the optimal tourniquet inflation pressure is a topic of debate. The current approach involves using a constant tourniquet pressure, although this is associated with the potential to augment the risk of tourniquet-associated complications. The Association of Surgical Technologists recommends a tourniquet pressure of systolic blood pressure plus 50 mm Hg for the upper limb and 100 mm Hg for the lower limb. Nevertheless, this method lacks robust support from high-quality medical literature. Therefore, the study aimed to compare the hemostatic efficacy and disparities in tourniquet pressure settings based on systolic blood pressure versus those using the constant-pressure method. The findings might outline the theoretical framework necessary for advocating for tourniquet pressure setups guided by systolic blood pressure. Methods/design This randomized controlled study classified the tourniquet pressure regimen into two groups: one based on the patient's systolic blood pressure (the study group) and the other using a constant pressure (the control group). The study included patients aged between 16 and 70 who presented with fresh fractures (less than 3 weeks) of the lower and upper limbs. All the included patients required surgical treatment involving the intraoperative use of a tourniquet and had no contraindications to this surgery. Our primary outcome was to assess the surgeon's satisfaction with the hemostasis achieved in the operative field. We also examined the changes in the circumference of the limb where the tourniquet was applied and tracked any postoperative complications and their incidence. The study ultimately encompassed 144 patients. Discussion Despite the prevalent use of tourniquets in surgical operations related to limb fractures, conflicting viewpoints persist concerning the adjustments in pressure and other elements. The study aimed to compare the hemostatic efficacy and disparities in tourniquet pressure settings based on systolic blood pressure versus those using the constant-pressure method. Study registration The study was duly recorded in the Chinese Clinical Trial Registry on May 13, 2022 (Registration number: ChiCTR2200059867). Registration website https://www.chictr.org.cn/showproj.aspx?proj=162504.
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Affiliation(s)
- Zhi-jian Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital Affiliated to Capital Medical University, No.31 Xin Jie Kou East Street, Xi Cheng District, Beijing, 100035, China
| | - Cheng-hui Chen
- Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Zhe-lun Tan
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital Affiliated to Capital Medical University, No.31 Xin Jie Kou East Street, Xi Cheng District, Beijing, 100035, China
| | - Chang-run Li
- Department of Orthopedic Trauma, Shenzhen Second People's Hospital (The First Affiliated Hospital, Shenzhen University, Shenzhen Translational Medicine Institute), Shenzhen, 518035, China
| | - Han Fei
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital Affiliated to Capital Medical University, No.31 Xin Jie Kou East Street, Xi Cheng District, Beijing, 100035, China
| | - Xiang Yu
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital Affiliated to Capital Medical University, No.31 Xin Jie Kou East Street, Xi Cheng District, Beijing, 100035, China
| | - Dong-chen Yao
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital Affiliated to Capital Medical University, No.31 Xin Jie Kou East Street, Xi Cheng District, Beijing, 100035, China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital Affiliated to Capital Medical University, No.31 Xin Jie Kou East Street, Xi Cheng District, Beijing, 100035, 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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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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Efficacy of arterial occlusion pressure estimation-based tourniquet pressure settings in upper limb surgery. J Orthop Sci 2022; 27:1051-1055. [PMID: 34315653 DOI: 10.1016/j.jos.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/25/2021] [Accepted: 06/09/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The use of a minimal individualized effective pneumatic tourniquet pressure is recommended to avoid pressure related complications in extremity surgery. The aim of this study was to investigate the efficacy of arterial occlusion pressure estimation-based tourniquet pressure settings in upper limb surgery. METHODS Hundred and fifteen patients undergoing upper limb surgeries were enrolled in the present study. Arterial occlusion pressure estimation formula was used and a safety margin of 20 mmHg was added to arterial occlusion pressure in the tourniquet pressure setting. Primary and secondary endpoints were the amount of tourniquet pressure and its effectiveness respectively. Other outcome measures included the tourniquet pressure setting time and tourniquet related complications. Surgical team unaware of the tourniquet pressure assessed the bloodless surgical field. RESULTS The mean initial and maximal tourniquet pressures were 171.5 ± 13.7 and 175.5 ± 13.2 mmHg, respectively. The effectiveness of the tourniquet was rated as "excellent" and "good" in the initial and middle stages, and at the end of the surgery of the procedure in 97.3%, 99.1%, and 100% of cases respectively. The mean tourniquet pressure setting time was 29.0 ± 3.7 s. No tourniquet related complications were observed. CONCLUSIONS Arterial occlusion pressure estimation-based tourniquet pressure setting is a practical and effective method, which allows using lower tourniquet pressures than previously used in the literature for upper extremity surgery.
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An alternative method for personalized tourniquet pressure in total knee arthroplasty: a prospective randomized and controlled study. Sci Rep 2022; 12:9652. [PMID: 35688920 PMCID: PMC9187725 DOI: 10.1038/s41598-022-13672-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/17/2022] [Indexed: 11/11/2022] Open
Abstract
Tourniquet use always carries potential risks, which can range from mild transient functional impairments of thigh pain, skin blisters to severe permanent dysfunction of limb paralysis, nerve injuries or compartment syndrome. The ideal method for minimizing intraoperative tourniquet pressure (TP) for reducing postoperative complications remains controversial. In this prospective, randomized and controlled study, we reinvestigated an estimation formula for TP based on thigh circumferences and systolic blood pressure (SBP) with two traditional methods for TP determination in total knee arthroplasty (TKA): SBP plus 100 mmHg and a fixed value of 300 mmHg. TP values and postoperative thigh pain scores were compared among three groups. The intraoperative TP value of the formula-calculated group was lower than that of the traditional groups (14.7 mmHg, P = 0.3475 and 94.7 mmHg, P < 0.0001, respectively), while no differences of hemostatic effect at the surgical fields and wound complications were detected among groups. The thigh pain scores at the tourniquet site decreased gradually over time and the estimation group had the lowest scores at each timepoint after surgery. Estimation method for TP was easy and rapid, without relying on specific equipment. It could provide a practical low TP and comparable hemostatic effect in TKA using an inflating tourniquet.
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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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Migliorini F, Maffulli N, Eschweiler J, Knobe M, Tingart M, Betsch M. Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism. Surgeon 2021; 20:241-251. [PMID: 33967006 DOI: 10.1016/j.surge.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The role of a tourniquet for knee arthroplasty remains controversial. The present Bayesian network meta-analysis investigated the role of various protocols for tourniquet inflation for knee arthroplasty, assessing data on pain control, clinical and functional outcomes, and the rate of deep vein thrombosis (DVT). MATERIAL AND METHODS The present Bayesian network meta-analysis was conducted according to the PRISMA guidelines. In March 2021, all clinical trials investigating the role of tourniquet use for knee arthroplasty were considered for inclusion. Groups were divided into those which used a tourniquet in knee arthroplasty procedures versus those which completed the procedure without tourniquet, or with varying protocols of tourniquet use. The hierarchical random-effects model analysis was adopted in all comparisons. RESULTS Data from 54 articles (5497 procedures) were retrieved. The absence of tourniquet group evidenced the lowest rate of DVT, and scored the lowest in the visual analogic scale (VAS) at 24-48 h, 1, 3, and 12 months follow-up. The same group evidenced the greatest gain of motion at 3-days, 1 week, 1 month, 3 months, 6 months, and 12 months follow-up, and the highest Knee Society Rating System scores at 1, 3, and 12 months follow-up. Of the outcome data assessed, the straight-leg-raise test was markedly inconsistent: therefore, no recommendations from this test can be made. CONCLUSION With regards to the endpoints considered in the present study, knee arthroplasties undertaken without the use of a tourniquet perform better overall.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England, UK.
| | - Jörg Eschweiler
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Matthias Knobe
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Markus Tingart
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Marcel Betsch
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of the University Heidelberg, Mannheim, Germany.
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Migliorini F, Maffulli N, Aretini P, Trivellas A, Tingart M, Eschweiler J, Baroncini A. Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes. Arch Orthop Trauma Surg 2021; 141:1007-1023. [PMID: 33417033 PMCID: PMC8139941 DOI: 10.1007/s00402-020-03725-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data. MATERIAL AND METHODS The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons. RESULTS Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group. CONCLUSION For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
| | - Paolo Aretini
- Fondazione Pisana per la Scienza, Via Ferruccio Giovannini, 13, 56017 San Giuliano Terme, Pisa, Italy
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Markus Tingart
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Alice Baroncini
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
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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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Kasem SA, Al Menesy T, Badawy AA, Abd Elmawgoud A, Adel G, Badawy YA. Comparison between two mathematical methods to estimate arterial occlusion pressure and tourniquet effectiveness in lower limb surgery: a prospective, randomized, double blind, comparative study. J Clin Monit Comput 2019; 34:675-681. [PMID: 31346900 DOI: 10.1007/s10877-019-00366-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/17/2019] [Indexed: 12/01/2022]
Abstract
The effectiveness of two different methods for calculating the arterial occlusion pressure (AOP) to set tourniquet inflation pressures were assessed in patients underwent knee arthroscopy. Eighty patients were included in this study. Tourniquet inflation pressure was set by adding 20 mmHg of safety margin above the AOP value which was calculated by either the Tuncali et al. formula or Hong-yun Liu et al. formula. Primary outcome measures were the initial and maximum SBP, initial and maximum tourniquet inflation pressure, the secondary outcomes were the surgeon rating of the bloodlessness of the surgical field and tourniquet associated complications. There was significant difference in the initial tourniquet pressure (mmHg); it was 208 ± 12 and 262 ± 18 for group (A) and (B) respectively; also there was significant difference in the maximum tourniquet pressure (mmHg), it was 229 ± 14 and 283 ± 19 for group (A) and (B) respectively. There was no significant difference in the initial SBP-to- tourniquet inflation time, the initial SBP or the maximum SBP between the groups. Also, there was no significant difference in surgeon rating of the bloodlessness of the surgical field, at the start, middle and end of surgery. Hong-yun Liu et al. mathematical formula was found to be less effective than Tuncali et al. formula to estimate the least effective tourniquet pressure in lower limb surgery and we might consider it invalid to be used in the lower limb.Clinical trials registration number: NCT03706859 (Clinicaltrials.gov) and registration date: January, 2019. https://clinicaltrials.gov/ct2/show/NCT03706859.
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Affiliation(s)
- Samaa A Kasem
- Anesthesia Department, Faculty of Medicine, Beni Suef University, Street 10, Pyramids gardens, Giza, Egypt.
| | - Tarek Al Menesy
- Anesthesia Department, Faculty of Medicine, Beni Suef University, Street 10, Pyramids gardens, Giza, Egypt
| | - Ahmed A Badawy
- Anesthesia Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | | | - Ghada Adel
- Anesthesia Department, Faculty of Medicine, Cairo University, Giza, Egypt
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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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Tuncali B, Boya H, Kayhan Z, Arac S. Tourniquet pressure settings based on limb occlusion pressure determination or arterial occlusion pressure estimation in total knee arthroplasty? A prospective, randomized, double blind trial. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:256-260. [PMID: 29752149 PMCID: PMC6146010 DOI: 10.1016/j.aott.2018.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/15/2017] [Accepted: 04/11/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to compare the limb occlusion pressure (LOP) determination and arterial occlusion pressure (AOP) estimation methods for tourniquet pressure setting in adult patients undergoing knee arthroplasty under combined spinal-epidural anesthesia. METHODS Ninety-three patients were randomized into two groups. Pneumatic tourniquet inflation pressures were adjusted based either on LOP determination or AOP estimation in Group 1 (46 patients, 38 female and 8 male; mean age: 67.71 ± 9.17) and Group 2 (47 patients, 40 female and 7 male; mean age: 70.31 ± 8.27), respectively. Initial and maximal systolic blood pressures, LOP/AOP levels, required time to estimate AOP/determinate LOP and set the cuff pressure, initial and maximal tourniquet pressures and tourniquet time were recorded. The effectiveness of the tourniquet was assessed by the orthopedic surgeons using a Likert scale. RESULTS Initial and maximal systolic blood pressures, determined LOP, estimated AOP, duration of tourniquet and the performance of the tourniquet were not different between groups. However, the initial (182.44 ± 14.59 mm Hg vs. 200.69 ± 15.55 mm Hg) and maximal tourniquet pressures (186.91 ± 12.91 mm Hg vs. 200.69 ± 15.55 mm Hg) were significantly lower, the time required to estimate AOP and set the tourniquet cuff pressure was significantly less (23.91 ± 4.77 s vs. 178.81 ± 25.46 s) in Group II (p = 0.000). No complications that could be related to the tourniquet were observed during or after surgery. CONCLUSION Tourniquet inflation pressure setting based on AOP estimation method provides a bloodless surgical field that is comparable to that of LOP determination method with lower pneumatic inflation pressure and less required time for cuff pressure adjustment in adult patients undergoing total knee arthroplasty under combined spinal epidural anesthesia.
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Affiliation(s)
- Bahattin Tuncali
- Department of Anesthesiology and Reanimation, Baskent University Zubeyde Hanim Practice and Research Center, Izmir, Turkey.
| | - Hakan Boya
- Department of Orthopedics and Traumatology, Baskent University Zubeyde Hanim Practice and Research Center, Izmir, Turkey.
| | - Zeynep Kayhan
- Department of Anesthesiology, Baskent University School of Medicine, Ankara, Turkey.
| | - Sukru Arac
- Department of Orthopedics and Traumatology, Baskent University Zubeyde Hanim Practice and Research Center, Izmir, Turkey.
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Lee OS, Lee MC, Han HS. Efficacy and safety of a new elastic tourniquet cuff in total knee arthroplasty: a prospective randomized controlled study. Biomed Eng Online 2017; 16:102. [PMID: 28789655 PMCID: PMC5549295 DOI: 10.1186/s12938-017-0393-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 08/04/2017] [Indexed: 11/21/2022] Open
Abstract
Background The effects of cuff shape, timing of tourniquet application, and automated systems using limb occlusion pressure (LOP) have been reported to minimize the appropriate tourniquet pressure. However, studies on the raw material of the cuff itself to reduce the complications related to the tourniquet have been very rarely reported. The purpose of this study is to report the efficacy and safety of a tourniquet system with a new elastic cuff in which pressure is set with LOP in total knee arthroplasty (TKA). Methods A total of 63 patients who underwent primary TKA for osteoarthritis were enrolled from July to December 2015. Thirty-one patients were allocated to the new elastic cuff group and 32 in the conventional cuff group. Bloodless surgical field, pain visual analog scale (VAS) on the thigh, thigh circumference, range of motion, incidence of deep vein thrombosis, and muscle enzyme level after surgery were checked and compared between the 2 groups. Results Only 1 of the 31 patients in the elastic cuff group required more pressure for obtaining a bloodless surgical field, whereas 4 of the 32 patients in the conventional cuff group required more pressure to complete surgery without being disturbed by sustained bleeding. Two patients in the conventional cuff group needed treatment for blisters and bullae at the tourniquet application site. There was no difference in pain VAS score, thigh circumference, range of motion, incidence of deep vein thrombosis, and level of muscle enzyme. Conclusions A new elastic tourniquet cuff provided a more proper bloodless surgical field with less adjustment of tourniquet pressure despite a similar level of tourniquet pressure compared to the conventional cuff and had a low incidence of skin complications on the site of tourniquet application in TKA. These benefits make it an effective and safe medical device for orthopedic surgery requiring a tourniquet, such as TKA.
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Affiliation(s)
- O-Sung Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, South Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea.
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Soft-tissue damage during total knee arthroplasty: Focus on tourniquet-induced metabolic and ionic muscle impairment. J Orthop 2017; 14:347-353. [PMID: 28706378 DOI: 10.1016/j.jor.2017.06.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/22/2017] [Indexed: 01/16/2023] Open
Abstract
PURPOSE Advantages of tourniquet use in TKA include benefits for surgeons and patients, varying from a bloodless operation site to a reduced intervention time. The time under ischemia and the reperfusion period are crucial phases for affected soft-tissue, most commonly the extensor mechanism. CASE REPORTS documented its impact on soft-tissue, ranging from necrotic muscle damage to systemic inflammation. Recently, research regarding tourniquet application patterns discuss clinical outcome parameters in the context of soft-tissue damage, excluding the underlying pathophysiological mechanisms. METHODS This review summarizes the molecular aspects of soft-tissue damage occurring during tourniquet application in TKA with special focus on ischemia/reperfusion injury. Recent meta-analyses and original trials were reviewed for data on muscle damage and are presented. CONCLUSION Although underlying pathomechanisms are well known and presented, clinical orthopedic research has so far not addressed this issue. In context of physical training, positive effects regarding postoperative recovery might be possible if more attention is paid to prepare involved muscle preoperatively to TKA (prehabilitation).
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Vertullo CJ, Nagarajan M. Is cement penetration in TKR reduced by not using a tourniquet during cementation? A single blinded, randomized trial. J Orthop Surg (Hong Kong) 2017; 25:2309499016684323. [PMID: 28139192 DOI: 10.1177/2309499016684323] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Despite suggestions that tourniquet inflation during total knee replacement reduces bleeding and hence improves cement penetration, no studies exist supporting this widely held belief. In this single-blinded, single-surgeon, randomized controlled trial, the tourniquet inflation during cementation group ( n = 20) did not have greater tibial cement penetration compared to a no tourniquet group ( n = 20). No statistically significant differences in semiautomatic digitally measured average and central radiographic tibial plateau penetration values were observed between the two groups ( p = 0.93; p = 0.84). Tourniquet inflation during cementation does not appear to improve tibial cementation penetration.
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Affiliation(s)
- Christopher John Vertullo
- 1 Knee Research Australia, Orthopaedic Surgery and Sports Medicine Centre, Benowa, QLD, Australia.,2 Menzies Health Institute Queensland, Griffith University, QLD, Australia
| | - Manickaraj Nagarajan
- 1 Knee Research Australia, Orthopaedic Surgery and Sports Medicine Centre, Benowa, QLD, Australia
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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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Comparison of quadriceps muscle volume after unilateral total knee arthroplasty with and without tourniquet use. Knee Surg Sports Traumatol Arthrosc 2016; 24:2595-605. [PMID: 26590567 DOI: 10.1007/s00167-015-3872-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/10/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Determination of the effect of tourniquet use in total knee arthroplasty (TKA) on thigh and quadriceps muscle volume using magnetic resonance imaging (MRI). METHODS A total of 148 knees of 74 patients (mean age 66.5 ± 4.8 years; female/male, 62/12) with bilateral primary varus gonarthrosis underwent unilateral TKA with a tourniquet (Group A, n = 35) or without a tourniquet (Group B, n = 39). The total thigh volume and connective, bone, and muscle tissue volumes were stereologically measured on preoperative and postoperative MRI. The Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were calculated to evaluate functional outcomes. RESULTS After TKA, the knees of patients in Group A exhibited a significant decrease in all tissue measurements, except bone tissue volume; however, the knees of patients in Group B exhibited no significant difference in tissue measurements. Although no difference was found between the operated and contralateral non-operated thighs (4076.9 and 4073.4 cm(3), respectively) in Group B postoperatively at 1 month (p > 0.05), the operated thighs had lost 20 % of its volume in Group A postoperatively at 1 month (p < 0.001). A significant difference was found in all tissue measurements, except the connective and bone tissue volumes of the thigh between the operated and contralateral non-operated knees in Group A. No significant difference was identified between the operated and contralateral non-operated knees in Group B. The total WOMAC score was significantly higher, and the total KSS was significantly lower in Group A than in Group B during the postoperative follow-up period of 1-6 months (p < 0.001 for all) but not 12 months (n.s.). CONCLUSION Tourniquet use in TKA decreases the thigh and quadriceps muscle volumes and postoperatively delays the recovery of knee function. Therefore, caution should be exercised for tourniquet use during TKA in daily clinical practice and using alternative methods for tourniquet application in preventing intraoperative blood loss. LEVEL OF EVIDENCE III.
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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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