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

Does the Use of a Tourniquet Influence Five-Year Outcomes Following Total Knee Arthroplasty?

BACKGROUND

A tourniquet is commonly used during total knee arthroplasty (TKA) to improve surgical field visibility and minimize blood loss. While the short-term effects of tourniquet use on postoperative outcomes have been studied extensively and found to be minimal, its influence on longer-term outcomes remains underexplored. This study examined tourniquet use in TKA with up to 5-year follow-up.

METHODS

In this post hoc analysis of a randomized controlled trial, 227 patients who underwent primary TKA in the tourniquet (T) group (n = 112) or no tourniquet (NT) group (n = 115) were evaluated. Clinical outcomes and patient-reported outcome measures were compared between the two groups.

RESULTS

The T group had non-significant trends toward reduced blood loss (131.8 versus 116.7 mL, P = 0.098) and shorter operative time (97.8 versus 95.7 minutes, P = 0.264), with slightly higher postoperative day one visual analog scale pain scores (3.1 versus 3.6, P = 0.197). Length of stay (2.0 versus 2.1 days, P = 0.837) and home discharge rate (88.7 versus 92.0%, P = 0.340) were comparable. The NT group had 3 90-day readmissions, while none occurred in the T group (2.7 versus 0%, P = 0.081). The active range of motion at the final follow-up was similar between groups (108.3 versus 106.5 degrees, P = 0.457). All-cause revision rates at 5 years were comparable between the NT and T groups (5.2 versus 3.6%, P = 0.546). Kaplan-Meier survivorship analysis revealed comparable aseptic implant survival at 5 years (P = 0.769). There were no significant differences in Knee injury and Osteoarthritis Outcome Score for Joint Replacement, Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, PROMIS pain interference, or PROMIS physical health scores at 3 months, 1 year, and 5 years postoperatively.

CONCLUSIONS

Using a tourniquet during primary TKA was not associated with differences in clinical or patient-reported outcomes at up to 5-year follow-up. These findings suggest that tourniquet use in TKA can be left to the surgeon's discretion.

LEVEL OF EVIDENCE

III.

Comparison of total blood loss between limited tourniquet use and conventional tourniquet use in total knee arthroplasty: a randomized controlled trial

BACKGROUND

This study examined the differences in total blood loss, the need for blood transfusions, length of hospital stay, wound grading scores, incidence of venous thromboembolism (VTE), and reoperation rates between conventional and limited tourniquet use during unilateral primary total knee arthroplasty (TKA).

METHODS

This double-blind, randomized controlled trial included 90 patients undergoing unilateral primary TKA. Forty-five patients were allocated to the limited tourniquet use group (LIM-TKA), and 45 to the conventional tourniquet use group (CON-TKA). The study analyzed differences in total blood loss, the need for blood transfusions, wound grading scores, incidence of VTE, length of hospital stay, and reoperation rates.

RESULTS

The mean total blood loss in the LIM-TKA group was 589.55 ± 238.2 ml, significantly lower than the 692.31 ± 276.15 ml observed in the CON-TKA group (P = 0.031). Significantly poorer wound grades were seen in the CON-TKA group compared to the LIM-TKA group, with 23 vs. 34, 15 vs. 11, 5 vs. 0, 1 vs. 0 and 1 vs. 0 patients, respectively, having grade 1, 2 A, 2B, 2 C and 3 A wounds according to the Southampton Scoring System (P = 0.032). Patients in the LIM-TKA group also had a shorter hospital stay versus the CON-TKA group (5.6 ± 1.28 vs. 7.2 ± 4.06 days, P = 0.006). The rates of blood transfusion, VTE complications, and reoperation were similar between both groups.

CONCLUSION

LIM-TKA results in significantly lower total blood loss and improved wound grading scores, as well as a decreased length of hospital stay compared to CON-TKA. LIM-TKA could be a suitable option for surgeons aiming to minimize tourniquet-related adverse outcomes while maintaining a dry bone surface during TKA cementation.

CLINICAL TRIAL NUMBER

This study was retrospectively registered at Thai Clinical Trials Registry (thaiclinicaltrials.org) on July 28, 2024.

CLINICAL TRIAL NUMBER

TCTR20240728002.

Tourniquet does not affect intraoperative kinematics during total knee arthroplasty: Results of a prospective study using a robotic assistance system

PURPOSE

Tourniquet use during total knee arthroplasty (TKA) remains controversial. There are limited data demonstrating the effect of tourniquet use on flexion and extension gaps. The use of a tourniquet can theoretically affect the kinematics of the knee joint, specifically the extension and flexion gaps and the laxity, by mechanically compressing the soft tissues including the muscles above the knee joint. Therefore, this study was designed to prospectively evaluate changes in flexion and extension gaps with and without the use of a tourniquet.

METHODS

The following prospective study included 50 consecutive patients who underwent TKA using a surgical robot. The inclusion criteria were advanced osteoarthritis (OA) and varus-alignment or valgus-alignment <3° (hip-knee-ankle angle, standing long-leg X-ray), and the exclusion criteria were BMI >35 kg/m2 and mechanical axis in >3° valgus. A CR-TKA was performed, and the medial and lateral gaps (in mm) throughout the full range of motion in 10° increments were recorded. The procedure was conducted both with and without an applied tourniquet (350 mmHg).

RESULTS

No significant differences were observed in the medial joint space. By contrast, the lateral gap showed significant differences in 10-20° of flexion (with a tourniquet 1.9 mm vs. without a tourniquet 2.1 mm, p = 0.018), 20-30° (1.6 vs. 1.8 mm, p = 0.02), 100-110° (0.9 vs. 1.1 mm, p = 0.021), and 110-120° (0.8 vs. 1 mm, p = 0.038). Thus, at the above degrees of flexion on the lateral side, there was a decrease in the mean of 0.2 mm with the use of a tourniquet.

CONCLUSION

Although the use of a tourniquet showed a detectable change in the lateral gap in four 10° segments of flexion, clinical relevance with an average difference of 0.2 mm is not achieved. Thus, the use of a tourniquet in TKA can still be advocated based on the presented data.

LEVEL OF EVIDENCE

Level I.