Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery

The tourniquet's effects on skeletal muscle during total knee arthroplasty

This study investigates the impact of perioperative tourniquet on skeletal muscle cells during total knee arthroplasty (TKA) and its effects on the gene expression of apoptotic, inflammatory, and angiogenic pathways. The randomized controlled trial included 44 patients undergoing TKA. The patients were randomized to undergo surgery with (n = 23) or without (n = 21) tourniquet. The tourniquet was inflated before skin incision and deflated before wound closure in the tourniquet group. Biopsies from the lateral vastus muscle were obtained from both groups before wound closure and 8 weeks after surgery. The messenger ribonucleic acid (mRNA) expression and protein levels of angiopoietin-like 4 (ANGPTL4), Hypoxia-inducible Factor 1α, and Vascular Endothelial Growth Factor Alpha (VEGF-A) in the biopsies were examined by reverse transcription-quantitative polymerase chain reaction and tissue microarray, respectively. Differences in mean values (ΔCt for mRNA expression and staining positivity for protein expression) were compared with t-tests. The apoptotic marker BID and the angiogenic marker VEGF-A were significantly lower in the tourniquet group compared to the control group (p = 0.03, p = 0.047). However, there was a significant upregulation of VEGF-A 8 weeks after surgery in the tourniquet group compared to perioperative biopsies (p = 0.002), indicating persistent changes. A significant upregulation in protein expression of the angiogenic marker ANGPTL4 was found perioperatively in the tourniquet group (p = 0.02). Our results demonstrate that the angiogenic gene expression is significantly altered by the tourniquet, the effects of which might contribute to postoperative interstitial edema, increased pain, and decreased muscle strength. These effects could lead to delayed rehabilitation and ultimately reduced patient satisfaction after TKA.

Introducing a new proforma for the safe use of intraoperative tourniquets in orthopaedic surgery

INTRODUCTION

The routine use of pneumatic tourniquets in orthopaedic surgery is widely adopted in current practice; however, practice varies considerably based mainly on anecdotal and cultural traditions. This Quality Improvement Project evaluated current service as per the newly published British Orthopaedic Association Standards for Trauma & Orthopaedics guideline on 'The Safe Use of Intraoperative Tourniquets'.

METHODS

Patient records were reviewed retrospectively for all patients who underwent orthopaedic surgery in September 2021 at one NHS hospital trust. Simultaneously, a nine-question survey was distributed to the orthopaedic teams allowing assessment of non-quantifiable aspects of the guidelines. The results were delivered as a local presentation, and trust-wide dissemination of posters using the mnemonic 'PRESSURE' was used to educate staff. The quantitative audit was repeated twice, after this intervention (March 2022) and after the advent of a new electronic patient record system with an online proforma (January 2023).

RESULTS

There was significant improvement (p<0.05) in all aspects of tourniquet documentation between the audit cycles. Maximum advised tourniquet duration was exceeded in <2% of cases regardless of guideline publication. Recommended pressures were used in less than one-third of cases in all audit cycles, with no significant change throughout. More than 50% of respondents sized their tourniquet on 'whatever looked best fit'.

CONCLUSIONS

Despite tourniquet usage being part of the UK Trauma & Orthopaedic Surgery curriculum, this study is the first to highlight a lack of compliance with 'gold standard' guidelines and the need for increased training for staff to ensure patients are exposed to the safest possible environment. Although electronic proformas can aid recording of information, the limitation to change is cultural tradition and anecdotal experience.

Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty

Background

Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways.

Methods

A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117).

Results

No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001).

Conclusions

Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

Can We Forgo the Use of Tourniquets in Total Knee Arthroplasty?

Objective  To analyze whether there is more bleeding in patients undergoing total knee arthroplasty (TKA) without using a tourniquet. The secondary objectives were to analyze the operative time, the length of hospital stay, the need for transfusion, and the complication rate. Methods  The present is a retrospective study through the analysis of medical records. The patients were divided into two groups: TKA with and without the use of a tourniquet. Reductions in the levels of hemoglobin and packed cell volume 24 h and 48 h after surgery, the operative time, the length of hospital stay, the need for transfusion, and the rate of complications up to 6 months postoperatively were compared between the groups. Results  During the period analyzed, 104 patients underwent TKA, and 94 were included in the study. There were no differences between the groups regarding the mean values of hemoglobin and packed cell volume before surgery ( p  = 0.675 and p  = 0.265), 24 h ( p  = 0.099 and p  = 0.563), and 48 h ( p  = 0.569 and p  = 0.810) after the procedure. Neither were there differences between the groups in terms of the operative time and the length of hospital stay ( p  = 0.484 and p  > 0.05). Moreover, there were no differences regarding the need for transfusion and the complication rate. Conclusion  It is possible to forgo the use a tourniquet in TKA without a significant change in hemoglobin and packed cell volume levels 24 h and 48 h after surgery when compared with the group using a tourniquet. There were no significant differences in the total operative time, length of stay, need for transfusion, and complication rate.

Intraosseous Versus Intravenous Vancomycin in Tourniquetless Primary Total Knee Arthroplasty: A Randomized Trial

INTRODUCTION

Intraosseous (IO) administration of vancomycin at the time of total knee arthroplasty (TKA) has been shown to be safer and more effective than intravenous (IV) administration at preventing early periprosthetic joint infection. Previous studies have relied on tourniquet inflation to enhance local tissue concentrations and mitigate systemic release.

METHODS

A single-blinded, randomized clinical trial was performed on 20 patients (10 IV, 10 IO) undergoing primary TKA. The control (IV) group received weight-dosed vancomycin approximately 1 hour prior to the incision and weight-dosed cefazolin immediately prior to the incision. The interventional (IO) group received weight-dosed cefazolin immediately prior to the incision and 500 mg of vancomycin delivered via the IO technique at the time of the incision. Systemic samples for vancomycin levels were taken prior to the incision and at closure. During the procedure, tissue samples were taken from the distal femur, proximal tibia, and suprapatellar synovium. There were no differences in patient demographics or changes in serum creatinine from preoperative to postoperatively between groups.

RESULTS

Significant differences in systemic vancomycin levels (ug/mL) were found at the start of the case (IV = 27.9 ± 4.9 versus IO = 0 ± 0, P = 0.0004) and at the end of the case (IV = 19.6 ± 2.6 versus IO = 7.8 ± 1.0, P = 0.001). No significant differences were seen in the average vancomycin concentration in the distal femur (IV = 61.0 ± 16.0 versus IO = 66.2 ± 12.3, P = 0.80), proximal tibia (IV = 52.8 ± 13.5 versus IO = 57.1 ± 17.0, P = 0.84), or suprapatellar synovial tissue (IV = 10.7 ± 5.3 versus IO = 9.0 ± 3.3, P = 0.80). There were no complications associated with vancomycin administration in either group.

CONCLUSION

This study demonstrates the utility of IO vancomycin in tourniquetless TKA with similar local tissue and significantly lower systemic concentrations than IV administration.

The Effect of Tranexamic Acid With or Without Tourniquet on Blood Loss in Total Knee Arthroplasty at a Community Hospital

Tourniquets have long been used in total knee arthroplasty due to the theoretical improvement of bleeding control, integration of cement-bone interface, visibility, and efficiency of the overall surgery. However, this has become increasingly disputed. Comparative studies in total knee arthroplasty employing chemical prophylaxis, i.e., tranexamic acid, have been conducted. This retrospective cohort study evaluated the effect of tranexamic with or without a tourniquet on mean blood loss, hemoglobin, and length of stay in total knee arthroplasty patients. A total of 153 patients' records met the inclusion criteria, 95 patients (62%) were in the tranexamic acid-only group while 58 patients (38%) were in the tranexamic acid plus tourniquet group. Based on mean blood loss in mL (827.5 without vs. 810.1 with the tourniquet, p=0.805), hemoglobin counts in g/dL (12.6 without vs. 12.5 with the tourniquet, p=0.598), and length of stay in days (1.0 days without vs. 1.1 with the tourniquet, p=0.204), there was no statistical difference between the tranexamic alone vs. tranexamic plus tourniquet groups. There were no statistical differences in the mean BMI between groups (32.3 without vs. 32.4 with tourniquets, p=0.901). The patient population had more women (64.1%) than men (35.9%) (p=0.001), but no significant difference in gender based on tourniquet use (p=0.521). The tourniquet group averaged three years younger than the tranexamic alone group (age mean 68.2 without vs 65.3 with tranexamic, p=0.029). This study found no identifiable difference in the three observed variables, indicating that tourniquet provides limited to no additional benefit in reducing blood loss over tranexamic alone in total knee arthroplasty, while tranexamic alone has no deleterious decrease in mean hemoglobin or increase in length of stay.

A systematic review of tourniquet use in paediatric orthopaedic surgery: can we extrapolate from adult guidelines?

Purpose

Tourniquets are commonly used intraoperatively in orthopaedic surgery to control bleeding and improve visibility in the surgical field. Recent evidence has thrown into question the routine use of tourniquets in the adult population resulting in a British Orthopaedic Association standard for intraoperative use. This systematic review evaluates the evidence on the practice, benefits, and risks of the intraoperative use of tourniquets for trauma and elective orthopaedic surgery in the paediatric population.

Methods

A prospectively registered systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO: CRD42022359048). A search of MEDLINE, Embase, the Cochrane Library and a Grey literature search was performed from their earliest record to 23 March 2023. Studies reporting tourniquet data in paediatric patients undergoing orthopaedic surgery were included. Data extracted included demographics, involved limb, trauma versus elective use, tourniquet use as primary or secondary measure, and tourniquet parameters and complications.

Results

Thirty-nine studies were included. Tourniquet practices and information reporting varied considerably. Tourniquets were used uneventfully in the majority of patients with no specific benefits reported. Several physiological and biochemical changes as well as complications including nerve injury, compartment syndrome, skin burns, thrombosis, post-operative limb swelling, and pain were reported.

Conclusions

Tourniquets are routinely used in both trauma and elective paediatric orthopaedic surgery with no high-quality research affirming benefits. Severe complications associated with their use are rare but do occur. High-quality studies addressing their benefits, the exact indication in children, and the safest way to use them in this population are necessary.

Effect of intravenous low-dose norepinephrine on blood loss in non-tourniquet total knee arthroplasty under general anesthesia: a randomized, double-blind, controlled, single-center trial

OBJECTIVE

This prospective trial aimed to evaluate the effects of low-dose intravenous norepinephrine (NE) on intraoperative blood loss and bleeding from osteotomy sites during non-tourniquet total knee arthroplasty (TKA) under general anesthesia.

METHODS

A total of 120 patients who underwent TKA between December 2020 and May 2022 were enrolled and randomly assigned to the intravenous low-dose NE Group (NE Group) or the control group (C Group). During surgery, NE Group received 0.05-0.1 μg/(kg min) of NE intravenously to raise and maintain the patient's mean arterial pressure (MAP). C Group received the same dose of saline as placebo. Intraoperative blood loss, bleeding score at osteotomy sites, Δlactate levels (Lac), postoperative complications, and transfusion rate during hospitalization were compared between groups.

RESULTS

Intraoperative and osteotomy blood loss was significantly lower in the NE Group than in the C Group (P < 0.001). No significant difference was observed in ΔLac between groups (P > 0.05). There was no significant difference in complications between the groups 3 days after surgery (P > 0.05). In addition, there was no significant difference in blood transfusion rates between the two groups during hospitalization (P > 0.05).

CONCLUSION

In non-tourniquet TKA under general anesthesia, low-dose intravenous NE safely and effectively reduced intraoperative blood loss and provided a satisfactory osteotomy site while maintaining a higher MAP.

Cemented total knee arthroplasty provides greater knee range of motion at 2 years than cementless technique

INTRODUCTION

Optimal fixation method between cemented, cementless, and hybrid techniques for total knee arthroplasty (TKA) is still debated. The purpose of this study is to evaluate the clinical outcomes of patients undergoing cemented versus cementless TKA.

METHODS

We reviewed 168 patients who underwent a primary TKA at a single academic institution between January 2015 and June 2017. Patients were categorized into cemented (n = 80) or cementless (n = 88) groups. Only patients with greater than or equal to 2-year follow-up were included in the study. Multivariate regressions were performed to analyze the relationship between the surgical fixation technique and the clinical outcomes.

RESULTS

There were no differences in demographics or baseline operative characteristics between the two groups. The cemented group had fewer manipulations under anesthesia (MUA) (4 vs. 15, p = 0.01), longer intraoperative tourniquet times (101.30 vs. 93.55 min, p = 0.02), and increased knee range of motion (ROM) at final follow-up (111.48 vs. 103.75°, p = 0.02) compared to the cementless group.

DISCUSSION AND CONCLUSION

Both cemented and cementless component fixation are viable options for (TKA). This study found that patients who underwent a cemented TKA required fewer MUA's and had greater final ROM compared to patients undergoing cementless TKA. Additional research is required regarding cementless and cemented fixation. We believe that the choice of which fixation technique to use ultimately comes down to patient characteristics and surgeon preference.

A prediction nomogram for deep venous thrombosis risk in patients undergoing primary total hip and knee arthroplasty: a retrospective study

INTRODUCTION

Deep venous thrombosis (DVT) prediction after total hip and knee arthroplasty remains challenging. Early diagnosis and treatment of DVT are crucial. This research aimed to develop a nomogram for early DVT prediction.

METHODS

A total of 317 patients undergoing primary total hip and knee arthroplasty in Sun Yat-sen Memorial Hospital were enrolled between May 2020 and September 2022. Data from May 2020 to February 2022 were used as the development datasets to build the nomogram model (n = 238). Using multivariate logistic regression, independent variables and a nomogram for predicting the occurrence of DVT were identified. Datasets used to validate the model for internal validation ranged from March 2022 to September 2022 (n = 79). The nomogram's capacity for prediction was also compared with the Caprini score.

RESULTS

For both the development and validation datasets, DVT was found in a total of 38 (15.97%) and 9 patients (11.39%) on post-operative day 7 (pod7), respectively. 59.6% patients were symptomatic DVT (leg swelling). The multivariate analysis revealed that surgical site (Knee vs. Hip), leg swelling and thrombin-antithrombin complex (TAT) were associated with DVT. The previously indicated variables were used to build the nomogram, and for the development and validation datasets, respectively. In development and validation datasets, the area under the receiver operating characteristic curve was 0.836 and 0.957, respectively. In both datasets, the predictive value of the Nomogram is greater than the Caprini score.

CONCLUSIONS

A proposed nomogram incorporating surgical site (Knee vs. Hip), leg swelling, and thrombin antithrombin complex (TAT) may facilitate the identification of patients who are more prone to develop DVT on pod7.

Blood Loss in Primary Unilateral Total Knee Arthroplasty with Limited Tourniquet Application: A Randomized Controlled Trial

Background

Tourniquet application in total knee arthroplasty (TKA) has many benefits and may have a role in the incidence of perioperative complications. Our aims were to examine the safety of applying a tourniquet for a limited amount of time during primary unilateral TKA (specifically, during cementation and final component fixation only) and to compare perioperative complications between the limited-application group and the full-application group.

Methods

We conducted a randomized controlled study of 62 patients undergoing primary unilateral TKA. Patients were randomly allocated to either the limited or full tourniquet application. The follow-up period was 6 months. We evaluated intraoperative, postoperative, total, and hidden blood loss as the primary outcome measures and clearance of the surgical field, operative duration, and perioperative complications as the secondary outcome measures.

Results

We found a significant difference in surgical field clearance between the groups. There was no significant difference in total, hidden, or postoperative blood loss between the groups. Mean intraoperative blood loss was significantly lower in the full-application group than in the limited-application group (171.742 ± 19.710 versus 226.258 ± 50.290 mL; p = 0.001). Perioperative complications, including allogeneic blood transfusion rates, did not significantly differ between the groups.

Conclusions

Limited tourniquet application is safe to use in primary unilateral TKA and does not increase the incidence of perioperative complications or total blood loss when compared with a standard, full-time tourniquet application.

Level of Evidence

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effects of tourniquet on surgical site wound infection and pain after total knee arthroplasty: A meta-analysis

The application of a tourniquet (TNQ) for haemostasis in total knee arthroplasty (TKA) is controversial and lacking systematic evaluation. This meta-analysis assessed relevant international data to quantitatively evaluate the implications of using TNQ in TKA, further guide clinical diagnosis and treatment, and improve postoperative outcomes. A comprehensive computerised search of PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, VIP, and Wanfang databases was conducted to retrieve randomised controlled trials on the application of TNQ in TKA published from database inception to August 2023. The included data, ultimately comprising 1482 patients in 16 studies, were collated and subjected to meta-analysis using Stata 17.0 software. The results showed that the use of TNQ during TKA led to significantly higher rates of postoperative surgical site wound infection (3.96% vs. 1.79%, odds ratio: 2.15, 95% confidence intervals [CIs]: 1.11-4.16, p = 0.023) and wound pain scores on the first (standardised mean difference [SMD]: 0.65, 95% CI: 0.35-0.94, p < 0.001), second (SMD: 0.66, 95% CI: 0.01-1.31, p = 0.045), and third (SMD: 0.68, 95% CI: 0.31-1.05, pP < 0.001) day after the procedure. In conclusion, the application of TNQ in TKA increases the risk of postoperative surgical site wound infection and worsens short-term postoperative wound pain; therefore, TNQ should be used sparingly during TKA, or its use should be decided in conjunction with the relevant clinical indications and the surgeon's experience.

Intravenous Use of Tranexamic Acid in Total Knee Arthroplasty with no Tourniquet

Objective:  To identify blood transfusion requirements and postoperative complications in patients undergoing total knee arthroplasty (TKA) with no tourniquet and intraoperative intravenous administration of tranexamic acid. Methods:  This retrospective observational study analyzed 49 preopeative and postoperative medical records of patients undergoing TKA. A paired t-test compared changes in hemoglobin (HB) and packed cell volume (PCV), and an independent t-test with Welch correction compared HB and PCV changes between genders. A Spearman correlation test determined associations between age and days of postoperative hospitalization with HB and PCV changes. The significance level adopted was p < 0.05. Results:  The patients' mean age was 71.9 ± 6.7 years; most subjects were women (73.5%). The right side (59.2%) was the most affected. Only one participant required a blood transfusion, while three subjects had complications during the postoperative follow-up. No patient had a thromboembolic event. The median length of postoperative hospital stay was 2 days (interquartile range [IQR] = 1.0). There were reductions in HB and PCV levels between the pre-operative and postoperative period, and female patients had a higher HB reduction. Conclusion:  TKA with tranexamic acid and no tourniquet did not cause significant postoperative complications or require blood transfusions.

Use of a tourniquet is not associated with increased risk of venous thromboembolism after fast-track total knee arthroplasty: a prospective multicenter cohort study of 16,250 procedures

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE) is a serious postoperative complication after total knee arthroplasty (TKA). Use of a tourniquet has shown conflicting results for risk of VTE after TKA. We aimed to investigate the associated risk of VTE after TKA using tourniquet in a fast-track set-up as no previous data exists.

PATIENTS AND METHODS

We performed an observational cohort study from 9 fast-track centers including unilateral primary TKA from 2010-2017 with prospective collection of preoperative risk-factors and complete 90-day follow-up. Use of a tourniquet was registered in the Danish Knee Arthroplasty Register. Postoperative VTE was identified from health records. We performed risk analyses using a mixed-effects logistic regression model adjusting for previously identified risk factors.

RESULTS

Of the 16,250 procedures (39% males, mean age 67.9 [SD 10.0] years, median LOS 2 [interquartile range 2-3]) 12,518 (77%) were performed with a tourniquet. The annual tourniquet usage varied greatly between departments from 0% to 100%, but also within departments from 0% to 99%. There was no significant difference between the 2 groups with 52 (0.42%) VTEs in the tourniquet group vs. 25 (0.67%) in the no-tourniquet group (p = 0.06 for cumulative 90-day incidence of VTE). This association remained statistically insignificant for VTE using tourniquet after adjustment for previously identified risk factors.

CONCLUSION

We found no association between the use of a tourniquet and increased risk of 90-day VTE after primary fast-track TKA, irrespective of the length of time for which the tourniquet was applied.

With or without a Tourniquet? A Comparative Study on Total Knee Replacement Surgery in Patients without Comorbidities

Background and Objectives: This study aimed to determine the effects of tourniquet use and the complications of total knee arthroplasty (TKA) in patients without comorbidities to investigate whether tourniquet application can be employed without adverse effects and to assess its impact on the occurrence of any complications. Materials and Methods: A total of 106 patients who underwent unilateral TKA were divided randomly into two groups according to whether a tourniquet was used during the surgery or not. Patients with comorbidities (except arterial hypertension) were excluded from the study. Knee Injury and Osteoarthritis Outcome Score, joint range of motion, visual analog scale (VAS) score, total blood loss during and after surgery, postoperative analgesic consumption, and side effects were the main factors evaluated in the study. Results: In the tourniquet group, where the VAS scores were higher, the use of analgesics was also significantly higher. While there was no statistically significant difference in total blood loss between the tourniquet and non-tourniquet groups, the postoperative and occult blood losses were higher in the tourniquet group. The differences between the two groups in all other parameters were very small and not statistically significant. Conclusions: The findings of the current study suggest that when the comorbidities of patients are thoroughly documented and clarified prior to surgery, tourniquets should be applied selectively to individuals without any pre-existing health conditions.

The Impact of Tourniquet Usage on TKA Outcome: A Single-Center Prospective Trial

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.

Tourniquets can further reduce perioperative blood loss in patients on dexamethasone and tranexamic acid during cemented total knee arthritis: a single-center, double-blind, randomized controlled trial

BACKGROUND

Multiple doses of dexamethasone and tranexamic acid can inhibit postoperative inflammation and reduce fibrinolysis and perioperative blood loss in total knee arthroplasty. In this single-center, double-blind, randomized clinical trial, the aim was to investigate whether applying a tourniquet to patients on dexamethasone and tranexamic acid could further reduce perioperative blood loss.

MATERIALS AND METHODS

Patients who underwent cemented total knee arthroplasty at our hospital were randomized to receive a tourniquet (n = 71) or not (n = 70) during the procedure. All patients received multiple doses of dexamethasone and tranexamic acid perioperatively. The primary outcome was perioperative blood loss, while secondary outcomes were surgery duration, postoperative laboratory indices of inflammation and fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, and complications.

RESULTS

Using a tourniquet was associated with significantly lower intraoperative blood loss (P < 0.001) and total blood loss (P = 0.007) as well as significantly shorter surgery duration (P < 0.001). In contrast, the tourniquet did not significantly affect hidden blood loss, postoperative inflammation or fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, or complications.

CONCLUSIONS

The results of this randomized clinical trial demonstrate that applying a tourniquet during cemented total knee arthroplasty to patients receiving multiple doses of dexamethasone and tranexamic acid can further reduce perioperative blood loss without increasing the risk of inflammation, fibrinolysis, or other complications. Thus, it is advised to use tourniquets combined with dexamethasone and tranexamic acid to reduce perioperative blood loss and avoid tourniquet-related adverse events.

LEVEL OF EVIDENCE

Therapeutic Level I. Trial registration Chinese Clinical Trail Registry, ChiCTR2200060567. Registered 5 June 2022-retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=171291.

Tourniquet use does not impact trajectory of total knee arthroplasty early recovery: A prospective, randomized controlled trial

BACKGROUND

The impact of tourniquet use on recovery after total knee arthroplasty (TKA) remains controversial. The purpose of this prospective, single blinded, randomized controlled trial, was to investigate the effect of tourniquet use on early recovery after TKA using a smartphone app-based patient engagement platform (PEP) with a wrist-based activity monitor to obtain more robust data on early recovery.

METHODS

There were 107 patients undergoing primary TKA for osteoarthritis who were enrolled (54 tourniquet [TQ+]; 53 no tourniquet [TQ-]). All patients utilized a PEP and wrist-based activity sensor for two weeks preoperatively and 90 days postoperatively to collect Visual Analog Scale (VAS) pain scores and opioid consumption, as well as weekly Oxford Knee Score (OKS) and monthly Forgotten Joint Score (FJS). There was no difference in demographics between groups. Formal physical therapy assessments were performed preoperatively and 3 months postoperatively. Independent sample t-tests were used for continuous data and Chi-squared and Fisher's exact tests were used for discrete data.

RESULTS

Tourniquet use did not have a statistically significant impact on daily VAS pain or opioid consumption during the first 30 days postoperatively (P > 0.05). Tourniquet use did not have a significant impact on OKS or FJS at 30 or 90 days postoperatively (P> 0.05), or on performance of formal physical therapy testing at 3 months postoperatively (P> 0.05).

CONCLUSIONS

Using a digital technology to collect daily patient data, we found that tourniquet use has no clinically significant negative impact on pain and function in the first 90 days after primary TKA.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Optimized Tourniquet Use in Primary Total Knee Arthroplasty: A Comparative, Prospective, and Randomized Study

BACKGROUND

The results of recent studies investigating tourniquet (TNQ) use for knee arthroplasty are controversial. Therefore, this study aimed to compare patients undergoing total knee arthroplasty who did not have a TNQ to those in whom an optimized TNQ protocol was applied.

METHODS

We prospectively evaluated 127 patients who had knee osteoarthritis who had undergone total knee arthroplasty and randomized them into two groups: "without TNQ" and "optimized TNQ" (TNQ inflation before skin incision, deflation after cementing, with pressure one hundred millimeters of mercury above the systolic blood pressure, and without articular suction drain usage). The means of surgery and TNQ duration, blood loss, number of blood transfusions, degree of pain, edema, range of motion (ROM), functional score over time, and postoperative complications were compared between the groups. Statistical significance was set at P < .05.

RESULTS

No significant differences were found in terms of surgical timing, blood loss, thigh and knee pain, edema, ROM, functional scores, and complications between the "without TNQ" and "optimized TNQ" groups.

CONCLUSION

The use of an optimized TNQ in primary total knee arthroplasty presents similar clinical results to surgery without a TNQ and did not increase the incidence of postoperative complications. Its use allowed surgery to occur with the benefits of a clean and dry surgical field provided by TNQ without increasing procedure-related comorbidities.

The use of tourniquet in primary total knee arthroplasty does not increase the risk of venous thromboembolism within 90 days of surgery: a Danish nationwide cohort study of 19,804 patients

PURPOSE

Existing evidence estimates a twofold risk of venous thromboembolisms (VTEs) if tourniquet is applied during total knee arthroplasties (TKAs). However, this estimate relies on multiple trials with a low number of patients analyzing VTEs as a secondary outcome. We hypothesized that tourniquet-use increases the risk of symptomatic VTE within 90 days of contemporary primary TKA and aimed to use the extensive Danish healthcare registries to quantify this risk.

METHODS

Prospectively collected registry data from Danish patients receiving primary TKAs between 2014 and 2018 were included in the study. Patients were divided by tourniquet-use during surgery. By merging information from four nationwide registries, the study included 44 baseline characteristics with the potential to confound the association between tourniquet-use and VTE. Incidence rate and odds ratios were used to compare the risk of VTE within 90 days of surgery.

RESULTS

19,804 patients of whom 10,111 (51%) were operated with tourniquet and 9693 (49%) without were included. The mean age (SD) was 70 (9) in both groups and 62% were females in the tourniquet group compared with 61% in the no tourniquet group. The groups were similarly comparable across all other baseline characteristics except type of post-operative thromboprophylaxis, type of anaesthesia, implant fixation, and year of surgery. The 90-days incidence of VTE was 0.77% (95% CI 0.60-0.94) in the tourniquet group compared with 1.10% (95% CI 0.90-1.31) in the no tourniquet group. Following adjustment for the unbalanced confounders, the odds ratio for VTE was 0.77 (95% CI 0.54-1.10) associated with tourniquet-use.

CONCLUSION

In contemporary TKAs the rate of VTE within 90 days is low and not significant altered by tourniquet-use. Thus, tourniquet can safely be applied during primary TKA-surgery without jeopardizing the risk of postoperative VTE.

LEVEL OF EVIDENCE

II-prospective cohort study.

Distal radius fracture fixation using WALANT versus general and regional anesthesia: A systematic review and meta-analysis

BACKGROUND

WALANT (wide-awake local anaesthetic no tourniquet) has become a popular technique in upper limb surgery including distal radius fracture fixation. The purpose of this systematic review and meta-analysis is to assess the effectiveness of the WALANT technique in distal radius fracture fixation, and to compare it to both general and regional anaesthesia.

METHODS

Pubmed, Embase, and Scopus databases were searched on 26/06/21 according to the PRISMA guidelines with the following search terms: radius, WALANT, "local anesthetic", wide-awake surgery. All studies comparing WALANT with other forms of anaesthesia for distal radius fracture fixation were included.

RESULTS

110 articles were identified, six studies (410 patients) were included, 164 of these patients were in the WALANT group. Two patients (1.2%) in the WALANT group and seven (6.5%) in the regional anaesthesia group required conversion to general anaesthesia. There was no statistically significant difference in post-operative complications, intra-operative VAS pain scores, operative times, functional or radiological outcomes. A statistically significant 8.6 mls increase in pooled mean blood loss in the WALANT group was noted (p = 0.02) although the clinical significance of this is doubtful.

CONCLUSION

The WALANT technique for distal radius fracture fixation is non-inferior to regional and general anaesthesia. It is a safe and effective technique that surgeons may consider utilising, especially for patients not suitable for general anaesthetic or in centres in which there is a lack of access to specialist anaesthetic equipment and care.

Optimization of surgical tourniquet usage to improve patient outcomes: Translational cross-disciplinary implications of a surgical practice survey

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.

Does living at high altitude increase the risk of bleeding events after total knee arthroplasty? A retrospective cohort study

OBJECTIVE

Post-operative bleeding after total knee arthroplasty (TKA) is a frequent cause of post-operative complications. This study compared blood loss and indicators of coagulation and fibrinolysis between TKA patients living at low or high altitudes.

METHODS

We retrospectively analyzed 120 patients at our institution who underwent primary TKA from May 2019 to March 2020, and we divided them into those living in areas about 500 m or > 3000 m above sea level. We compared the primary outcome of total blood loss between them. We also compared them in terms of several secondary outcomes: coagulation and fibrinolysis parameters, platelet count, reduction in hemoglobin, hidden blood loss, intra-operative blood loss, transfusion rate, and incidence of thromboembolic events and other complications.

RESULTS

Total blood loss was significantly higher in the high-altitude group than in the low-altitude group (mean, 748.2 mL [95% CI, 658.5-837.9] vs 556.6 mL [95% CI, 496.0-617.1]; p = 0.001). The high-altitude group also showed significantly longer activated partial thromboplastin time, prothrombin time, and thrombin time before surgery and on post-operative day one, as well as increased levels of fibrinogen/fibrin degradation product on post-operative days one and three. Ecchymosis was significantly more frequent in the high-altitude group (41.7 vs 21.7%; relative risk (RR) = 1.923 [95% CI, 1.091-3.389]; p = 0.019). The two groups showed similar transfusion rates, and none of the patients experienced venous thromboembolism, pulmonary embolism, or infection.

CONCLUSION

High altitude may alter coagulation and fibrinolysis parameters in a way that increases risk of blood loss after TKA. Such patients may benefit from special management to avoid bleeding events.

Tourniquet use during primary total knee arthroplasty-a survey of Irish orthopaedic surgeons in 2022

BACKGROUND

Tourniquet use during primary total knee arthroplasty is a debated topic in the literature with no consensus on its optimal use.

AIM

To analyse current tourniquet practice amongst Irish orthopaedic surgeons performing primary total knee arthroplasty surgery. To evaluate if there has been a shift in practice in recent years and to explore potential reasons behind this.

METHODS

An eleven-question online survey was developed using the online platform SurveyMonkey. This was distributed by email to Irish orthopaedic surgeons via the Irish Institute of Trauma and Orthopaedic Surgery.

RESULTS

Fifty responses were included in the final analysis of this study. Eighteen (36%) respondents reported changing their tourniquet use in the past 5 years. Thirty-one (62%) respondents reported inflating the tourniquet for the entire case, with the remaining never applying a tourniquet (n = 6, 12%), applying a tourniquet but not routinely inflating it (n = 3, 6%), or inflating the tourniquet only during cementation (n = 5, 10%). The number of years of experience as a consultant appeared to impact tourniquet use in a bimodal pattern.

CONCLUSION

While the majority of Irish orthopaedic surgeons in this survey inflate a tourniquet for the entire surgical procedure, there is a definite shift towards reduced tourniquet use compared to previous Irish, UK, and American surveys.

Evaluation of the Influence of Short Tourniquet Ischemia on Tissue Oxygen Saturation and Skin Temperature Using Two Portable Imaging Modalities

BACKGROUND

The exact influence of tourniquet ischemia on a treated extremity remains unclear.

METHODS

Twenty patients received an operation on one hand under tourniquet ischemia. Twenty healthy volunteers received 10 min of tourniquet ischemia on one of their arms. Measurements of tissue oxygen saturation using near-infrared reflectance-based imaging and skin temperature of the dorsum of the hand were performed at five different timepoints (t0 was performed just before the application of the tourniquet ischemia, t1 directly after the application of the tourniquet ischemia, t2 before the release of the ischemia, t3 directly after the release of the ischemia, and t4 on the following day).

RESULTS

In both groups, tissue oxygen saturation dropped after the application of the tourniquet ischemia compared to t0 and increased after the release of the tourniquet ischemia. In the patient group, tissue oxygen saturation at t4 was higher compared to t0; in contrast, the level of tissue oxygen saturation in the participant group dropped slightly at t4 compared to t0. The measured skin temperature in the patient group showed an increase during the observation period, while it continuously decreased in the group of healthy participants.

CONCLUSIONS

Short-term ischemia did not appear to permanently restrict perfusion in this study design. The non-invasive imaging modalities used were easy to handle and allowed repetitive measurement.

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

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.

Peri-articular administration of tranexamic acid is an alternative route in total knee arthroplasty: a systematic review and meta-analysis

Background

As an antifibrinolytic agent, tranexamic acid (TXA) is increasingly used in total knee arthroplasty (TKA) to reduce blood loss. The administration of intravenous and intra-articular TXA has been well explored, but the most efficient way to administer TXA remains in question. Peri-articular injection (PAI) of TXA is a recently mentioned method. A meta-analysis of the efficacy of PAI TXA in patients after TKA should be performed.

Methods

A systematic search was performed within PubMed, Embase, and the Cochrane Library up to November 8, 2021. Two authors independently screened studies for eligibility and extracted data for analysis. The primary outcome was haemoglobin change. The secondary outcomes were haematocrit change, total drainage volume, thromboembolic events, and blood transfusion.

Results

A total of ten studies were included in this meta-analysis. The results indicated that there was a significant decrease in haemoglobin change when using PAI TXA compared with no TXA (mean difference − 1.05; 95% CI − 1.28 to − 0.81; P < 0.00001; I² = 0%), but it had no significant differences compared with IA and IV (mean difference − 0.01; 95% CI − 0.17 to − 0.14; P = 0.85; I² = 39%). There were no significant differences between the TXA < 1.5 g subgroup (0.10, 95% CI − 0.27 to 0.46; P = 0.60; I² = 0%) and the TXA ≥ 1.5 g subgroup (0.18, 95% CI − 0.12 to 0.48; P = 0.24; I² = 74%). In addition, the combined group (PAI plus IV or IA) was superior to the IV or IA group in terms of haemoglobin change (mean difference − 0.51; 95% CI − 0.76 to − 0.27; P < 0.0001; I² = 19%). Regarding haematocrit change, the pooled result showed it was significantly less in the PAI group than the non-TXA group. Similarly, comparing it against the IV subgroup, the result revealed a difference in favour of the PAI group, with a mean difference of − 1.89 g/dL (95% CI − 2.82 to − 0.95; P < 0.0001; I² = 67%). For total drainage volume, the pooled result was in favour of PAI TXA over no TXA (297 ml, 95% CI − 497.26 to − 97.23; P = 0.004; I² = 87%), but it had no significant difference compared with IA and IV (mean difference − 37.98; 95% CI − 115.68 to 39.71; P = 0.34; I² = 95%). There was no significant difference in thromboembolic events (OR 0.74; 95% CI 0.25 to 2.21; P = 0.59; I² = 0%). Blood transfusion was not significantly different between the PAI group and the non-TXA group (OR 0.50; 95% CI 0.23 to 1.06; P = 0.07; I² = 21%), and there was no significant difference between PAI and the other two TXA injection methods (OR 0.72; 95% CI 0.41 to 1.25; P = 0.24; I² = 19%).

Conclusion

PAI has comparable effects to IV and IA injections. PAI is an alternative injection route of TXA for patients who have undergone TKA.

The Association between Two-Stage Tourniquet Application during Total Knee Replacement and Blood Loss: A Retrospective Cohort Study

Tourniquet use during total knee arthroplasty improves the surgical field, but is associated with several complications. The medical records of 506 patients who underwent elective total knee arthroplasty or total knee replacement from January 2017 to December 2020 were reviewed. A total of 331 patients who had undergone total knee arthroplasty were included. In the first half course group, the tourniquet was inflated with a pressure of 300 mmHg after manual banding before the incision and deflated after cement insertion. In the two-stage group, the tourniquet was inflated and deflated at the same stages of the procedure as in the first half course group. However, in this second group, the tourniquet was deflated for 15 min and then inflated again, and, finally, it was deflated after skin closure. The estimated blood loss, the number of patients who needed medications to control their blood pressure, and opioid usage at the post-anesthesia care unit were similar in both groups. The two-stage tourniquet technique was not related to reduced total blood loss in total knee arthroplasty.

Vascular Injuries During Hip and Knee Replacement

Vascular injuries associated with hip and knee arthroplasty are rare but can result in devastating outcomes for the patient. A sound knowledge of vascular anatomy, potential mechanisms of injury, and diagnosis and management of vascular injuries are vital to an arthroplasty surgeon. Identifying high-risk patients and procedures allows careful preoperative planning, which combined with meticulous intraoperative technique, may help avoid vascular complications. When vascular injuries do occur, early recognition and intervention are critical to an improved outcome.

Safety of Total Knee Arthroplasty without Using a Tourniquet in Elderly Patients

This study retrospectively compared the perioperative bleeding, hemodynamics, and clinical outcomes of total knee arthroplasty (TKA) performed with and without a tourniquet between two age groups. We grouped 103 patients with knee osteoarthritis who underwent primary TKA based on age at surgery: <76 years and ≥76 years. Tourniquet was used for TKA until March 2010 and stopped thereafter; hence, the patients were further classified according to TKA performed with or without a tourniquet. The differences in the operation time; perioperative bleeding; estimated bleeding; and hemoglobin (Hb) and hematocrit (Ht) levels immediately, 1 day, and 7 days postoperatively were evaluated. The clinical outcomes for range of motion, and Knee Society Knee Scores preoperatively and at 4 weeks postoperatively were assessed. Operation time was longer in the ≥76-year-old non-tourniquet group. No difference was observed in estimated bleeding among the groups. Changes in the Hb and Ht levels at postoperative days 1 and 7 were negatively correlated with age but were not different for TKA performed with or without a tourniquet in the ≥76-year-old-patient group. There were no differences in clinical outcomes among the groups. TKA can be performed with or without a tourniquet in patients aged ≥ 76 years with careful assessment of postoperative anemia.

Reappraisal of Limited Duration Tourniquet in Total Knee Arthroplasty: A Double-Blinded RCT

BACKGROUND

The majority of arthroplasty surgeons use a full duration of tourniquet while doing total knee arthroplasty. Recent literature suggests clinical dilemma about superior function with limited duration use of a tourniquet. The purpose of this study is to evaluate the time-dependent effects and clinical outcome of tourniquet in patients undergoing total knee arthroplasty (TKA) and to assess the incidence of adverse vascular events of the limb in TKA. This study is the first of its kind to evaluate all the serious vascular events prospectively.

METHODS

Sixty participants who underwent TKA in the duration of 1.5 years at a large single tertiary care centre were recruited and randomly allocated in two groups: Full duration tourniquet (n = 30) and tourniquet only during cementation (n = 30). All patients underwent preoperative and postoperative arterial and venous Doppler to evaluate the presence of thrombosis. The operative duration, blood loss, and clinical outcome (visual analogue scale, active knee range of motion, Knee Society score, and duration of stay) were recorded.

RESULTS

The incidence of vascular complications was not statistically significant in either group (P = 0.99). Tourniquet during cementation only group exhibited decreased postoperative pain on days 1, 2, and 3 (P < 0.01). But postoperative knee active range of motion was the same between the two groups with no significant postoperative complications.

CONCLUSION

Tourniquet use only during cementation could result in faster recovery and less pain during the early rehabilitation period with no influence over the incidence of serious vascular events.

TRIAL REGISTRY NUMBER

AIIMS/IEC/2018/475. This study was approved by the Research Ethics Committee at All India Institute of Medical Sciences, Jodhpur and was carried out at AIIMS (Jodhpur), India.

Perioperative Blood Loss Can Be Reduced If Total Knee Arthroplasty Was Performed in the Si Hour-Period, Compared with the Wei Hour-Period: A Retrospective Cohort Study

Objective

To investigate the efficacy and safety of performing primary unilateral total knee arthroplasty (TKA) in the “Si hour-period” meaning 09:00 a.m. to 11:00 a.m. (one of the 12 two-hour periods into which the day was traditionally divided, each being given the name of one of the 12 earthly branches), compared with the “Wei hour-period” (13:00–15:00).

Methods

Patient documentations were studied for those who underwent a primary unilateral TKA performed by the same surgical team with a tourniquet between January 2018 and January 2021 at our medical center. Eighty-four patients were enrolled and assigned into group A (in Si hour-period) and group B (in Wei hour-period). The main outcomes were total blood cell loss (TBL), hidden blood loss (HBL), visible blood loss (VBL), maximum hemoglobin (Hb) drop, and transfusion rate. Secondary outcomes were length of hospital stay (LOS), postoperative femorotibial mechanical axis (FTMA), FTMA correction, platelet count, plasma D-dimer (D-D), prothrombin time (PT), international normalized ratio (INR), and the incidence of postoperative complications.

Results

Group A showed statistical significance lower at the mean TBL, the mean HBL, and the maximum Hb drop (95% CI: −352.8 to −46.1,P=0.011, 95% CI: −348.0 to −40.1,P=0.014, and 95% CI: −9.5 to −0.7,P=0.023, respectively) after TKA than group B. The postoperative platelet count of group A was more significant than that of group B (95% CI:3.1 to 52.9, P=0.028). The VBL, transfusion rate, the LOS, postoperative FTMA, FTMA correction, plasma D-D, PT, INR, and the incidence of postoperative complications (wound complications, calf muscular vein thrombosis, infection, pulmonary embolism, and deep vein thrombosis) were similar between the two groups (P > 0.05, respectively).

Conclusion

Our study shows that blood loss can be reduced when TKA is performed in the “Si hour-period,” which may be due to increasing platelet count, and postoperative complications did not increase, compared with the Wei hour-period. We recommend that the selective operation, such as TKA, should be performed in the “Si hour-period” in clinical practice between the two hour-period.