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The effects of tourniquet on cement penetration in total knee arthroplasty

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Purpose

Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant’s “strength” and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients.

Methods

A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies.

Results

A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2–4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0–4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02).

Conclusion

Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.

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Availability of data and materials

The data used in this study is from the authors’ institution and is available from the corresponding author, RS, upon reasonable request.

References

  1. Ozkunt O, Sariyilmaz K, Gemalmaz HC, Dikici F (2018) The effect of tourniquet usage on cement penetration in total knee arthroplasty. Med (United States). https://doi.org/10.1097/MD.0000000000009668

    Article  Google Scholar 

  2. Dixon MC, Brown RR, Parsch D, Scott RD (2005) Modular fixed-bearing total knee arthroplasty with retention of the posterior cruciate ligament: a study of patients followed for a minimum of fifteen years. J Bone Jt Surg Ser A 87:598–603. https://doi.org/10.2106/JBJS.C.00591

    Article  Google Scholar 

  3. Parsch D, Krüger M, Moser MT, Geiger F (2009) Follow-up of 11–16 years after modular fixed-bearing TKA. Int Orthop 33:431–435. https://doi.org/10.1007/s00264-008-0543-x

    Article  CAS  PubMed  Google Scholar 

  4. Bass AR, McHugh K, Fields K et al (2016) Higher total knee arthroplasty revision rates among United States Blacks Than Whites. J Bone Jt Surg 98:2103–2108. https://doi.org/10.2106/JBJS.15.00976

    Article  Google Scholar 

  5. Curtin B, Malkani A, Lau E et al (2012) Revision after total knee arthroplasty and unicompartmental knee arthroplasty in the medicare population. J Arthroplasty 27:1480–1486. https://doi.org/10.1016/j.arth.2012.02.019

    Article  PubMed  Google Scholar 

  6. Namba RS, Inacio MC, Khatod M et al (2010) Risk factors for aseptic revision of primary total knee arthroplasty. J Arthroplasty 2:125. https://doi.org/10.1016/j.arth.2013.04.050

    Article  Google Scholar 

  7. Sharkey PF, Lichstein PM, Shen C et al (2013) Why are total knee arthroplasties failing today-has anything changed after 10 years? J Arthroplasty 29:1774–1778. https://doi.org/10.1016/j.arth.2013.07.024

    Article  Google Scholar 

  8. Why Are Total Knee Arthroplasties Failing Today—Has Anything Changed After 10 Years?- ClinicalKey. https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0883540313005421?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0883540313005421%3Fshowall%3Dtrue&referrer. Accessed 7 Nov 2019

  9. Sharkey PF, Hozack WJ, Rothman RH, et al (2002) Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res 404:7–13. https://doi.org/10.1097/00003086-200211000-00003

    Article  Google Scholar 

  10. Thiele K, Perka C, Matziolis G et al (2015) Current failure mechanisms after knee arthroplasty have changed: polyethylene wear is less common in revision surgery. J Bone Jt Surg Am 97:715–720. https://doi.org/10.2106/JBJS.M.01534

    Article  Google Scholar 

  11. Gapinski ZA, Yee EJ, Kraus KR et al (2019) The effect of tourniquet use and sterile carbon dioxide gas bone preparation on cement penetration in primary total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2019.03.050

    Article  PubMed  Google Scholar 

  12. Kurtz S, Ong K, Lau E et al (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Jt Surg - Ser A. https://doi.org/10.2106/JBJS.F.00222

    Article  Google Scholar 

  13. Kutzner I, Hallan G, Høl PJ et al (2018) Early aseptic loosening of a mobile-bearing total knee replacement: a case-control study with retrieval analyses. Acta Orthop 89:77. https://doi.org/10.1080/17453674.2017.1398012

    Article  PubMed  Google Scholar 

  14. Hampton CB, Berliner ZP, Nguyen JT et al (2020) Aseptic loosening at the tibia in total knee arthroplasty: a function of cement mantle quality? J Arthroplasty 35:S190–S196. https://doi.org/10.1016/J.ARTH.2020.02.028

    Article  PubMed  Google Scholar 

  15. Vanlommel J, Luyckx JP, Labey L et al (2011) Cementing the tibial component in total knee arthroplasty. which technique is the best? J Arthroplasty 26:492–496. https://doi.org/10.1016/j.arth.2010.01.107

    Article  PubMed  Google Scholar 

  16. Walker PS, Soudry M, Ewald FC, McVickar H (1984) Control of cement penetration in total knee arthroplasty. Clin Orthop Relat Res NO 185:155–164. https://doi.org/10.1097/00003086-198405000-00027

    Article  Google Scholar 

  17. Lutz MJ, Pincus PF, Whitehouse SL, Halliday BR (2009) The effect of cement gun and cement syringe use on the tibial cement mantle in total knee arthroplasty. J Arthroplasty 24:461–467. https://doi.org/10.1016/j.arth.2007.10.028

    Article  PubMed  Google Scholar 

  18. Walker PS, Greene D, Reilly D et al (1981) Fixation of tibial components of knee prostheses. J Bone Jt Surg Am 63:258–267

    Article  CAS  Google Scholar 

  19. Schlegel UJ, Bishop NE, Püschel K et al (2014) Comparison of different cement application techniques for tibial component fixation in TKA. Int Orthop 39:47–54. https://doi.org/10.1007/s00264-014-2468-x

    Article  PubMed  Google Scholar 

  20. Hofmann AA, Goldberg TD, Tanner AM, Cook TM (2006) Surface cementation of stemmed tibial components in primary total knee arthroplasty. minimum 5-year follow-up. J Arthroplasty 21:353–357. https://doi.org/10.1016/j.arth.2005.06.012

    Article  PubMed  Google Scholar 

  21. Rama KRBS, Apsingi S, Poovali S, Jetti A (2007) Timing of tourniquet release in knee arthroplasty: meta-analysis of randomized, controlled trials. J Bone Jt Surg Ser A. https://doi.org/10.2106/JBJS.F.00497

    Article  Google Scholar 

  22. Huang ZY, Pei FX, Ma J et al (2014) Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-014-1948-1

    Article  PubMed  PubMed Central  Google Scholar 

  23. Banwart JC, McQueen DA, Friis EA, Graber CD (2000) Negative pressure intrusion cementing technique for total knee arthroplasty. J Arthroplasty 15:360–367. https://doi.org/10.1016/S0883-5403(00)90762-9

    Article  CAS  PubMed  Google Scholar 

  24. Juliusson R, Flivik G, Nilsson J et al (1995) Circulating blood diminishes cement penetration into cancellous bone:in vivo studies of 21 arthrotic femoral heads. Acta Orthop 66:234–238. https://doi.org/10.3109/17453679508995531

    Article  CAS  Google Scholar 

  25. Majkowski RS, Bannister GC, Miles AW (1994) The effect of bleeding on the cement-bone interface. An experimental study. Clin Orthop Relat Res 293:297. https://doi.org/10.1097/00003086-199402000-00040

    Article  Google Scholar 

  26. Bam S, der Hart VC, Qgb F (2015) Effect of tourniquet application on postoperative functional outcome following total knee arthroplasty: a prospective cohort study. Orthop Muscular Syst 4:3. https://doi.org/10.4172/2161-0533.1000190

    Article  Google Scholar 

  27. Ejaz A, Laursen AC, Kappel A et al (2014) Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop 85:422–426. https://doi.org/10.3109/17453674.2014.931197

    Article  PubMed  PubMed Central  Google Scholar 

  28. Dennis DA, Kittelson AJ, Yang CC et al (2016) Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res 474:69–77. https://doi.org/10.1007/s11999-015-4393-8

    Article  PubMed  Google Scholar 

  29. Huang PS, Copp SN (2019) Oral opioids are overprescribed in the opiate-naive patient undergoing total joint arthroplasty. J Am Acad Orthop Surg. https://doi.org/10.5435/jaaos-d-18-00404

    Article  PubMed  Google Scholar 

  30. Clarke MT, Longstaff L, Edwards D, Rushton N (2001) Tourniquet-induced wound hypoxia after total knee replacement. J Bone Joint Surg Br 83:40–44

    Article  CAS  PubMed  Google Scholar 

  31. Tai TW, Chang CW, Lai KA et al (2012) Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. J Bone Jt Surg Ser A. https://doi.org/10.2106/JBJS.K.00813

    Article  Google Scholar 

  32. Goel R, Rondon AJ, Sydnor K et al (2019) Tourniquet use does not affect functional outcomes or pain after total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. J Bone Jt Surg Am 101:1821–1828. https://doi.org/10.2106/JBJS.19.00146

    Article  Google Scholar 

  33. Zak SG, Yeroushalmi D, Long WJ et al (2021) Does the use of a tourniquet influence outcomes in total knee arthroplasty: a randomized controlled trial. J Arthroplasty 36:2492–2496. https://doi.org/10.1016/J.ARTH.2021.02.068

    Article  PubMed  Google Scholar 

  34. Goel R, Rondon AJ, Sydnor K et al (2019) Tourniquet use does not affect functional outcomes or pain after total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. J Bone Joint Surg Am 101:1821–1828. https://doi.org/10.2106/JBJS.19.00146

    Article  PubMed  Google Scholar 

  35. Meneghini RM, Mont MA, Backstein DB et al (2015) Development of a modern knee society radiographic evaluation system and methodology for total knee arthroplasty. J Arthroplasty 30:2311–2314

    Article  PubMed  Google Scholar 

  36. Pfitzner T, von Roth P, Voerkelius N et al (2016) Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty. Knee Surg Sport Traumatol Arthrosc 24:96–101. https://doi.org/10.1007/s00167-014-3341-6

    Article  Google Scholar 

  37. Howard KI, Miller MA, Damron TA, Mann KA (2014) The distribution of implant fixation for femoral components of TKA: a postmortem retrieval study. J Arthroplasty 29:1863–1870. https://doi.org/10.1016/j.arth.2014.04.014

    Article  PubMed  PubMed Central  Google Scholar 

  38. Andrade MAP, Monte LFR, Lacerda GC et al (2022) Are cementation quality and clinical outcomes affected by the use of tourniquet in primary total knee arthroplasty? Arch Orthop Trauma Surg. https://doi.org/10.1007/S00402-021-03865-5

    Article  PubMed  Google Scholar 

  39. Migliorini F, Maffulli N, Aretini P et al (2021) Impact of tourniquet during knee arthroplasty: a Bayesian network meta-analysis of peri-operative outcomes. Arch Orthop Trauma Surg 141:1007–1023. https://doi.org/10.1007/S00402-020-03725-8

    Article  PubMed  PubMed Central  Google Scholar 

  40. Jawhar A, Stetzelberger V, Kollowa K, Obertacke U (2019) Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty. Knee Surg Sport Traumatol Arthrosc 27:2071–2081. https://doi.org/10.1007/s00167-018-5330-7

    Article  Google Scholar 

  41. Rizzo MG, Hall AT, Downing JT, Robinson RP (2021) High-viscosity versus a lower-viscosity cement penetration at dough phase in vivo in primary total knee arthroplasty. J Arthroplasty 36:1995–1999. https://doi.org/10.1016/J.ARTH.2021.02.010

    Article  PubMed  Google Scholar 

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Funding

This study did not receive any funding.

Author information

Authors and Affiliations

  1. Division of Adult Reconstruction, NYU Langone Orthopedic Hospital, Hospital for Joint Diseases, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA

    Stephen G. Zak, Alex Tang, Morteza Meftah & Ran Schwarzkopf

  2. Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA

    Robert Pivec & Matthew S. Austin

  3. Desert Orthopedic Center, Eisenhower Medical Center, Rancho Mirage, CA, USA

    Erik Schnaser

Authors
  1. Stephen G. Zak
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  7. Ran Schwarzkopf
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Contributions

SGZ: writing original draft, writing review and editing. AT: writing review and editing. RP: formal analysis and investigation. MM: conceptualization, writing-review and editing, participating surgeon. MSA: conceptualization, writing-review and editing, participating surgeon. ES: conceptualization, writing- review and editing, participating surgeon. RS: supervision, writing- review and editing, participating surgeon.

Corresponding author

Correspondence to Ran Schwarzkopf.

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Conflict of interests

Mr. Stephen G. Zak has no conflicts of interest. Mr. Alex Tang has no conflicts of interest. Dr. Robert Pivec has no conflicts of interest. Dr. Morteza Meftah received royalties from Innomed and owns stock in CAIRA surgical. Morteza Meftah is also a paid consultant for Intellijoint. Dr. Matthew S. Austin own stock in and is a paid speaker for Corin USA. Dr. Erik Schnaser is a paid speaker for Orthoalign, Smith & Nephew and Stryker; is a paid consultant for Smith & Nephew and Zimmer. Erik Schnaser also received research support from Lima and Smith & Nephew. Dr. Ran Schwarzkopf receives royalties from Smith & Nephew; is a paid consultant for Inteljoint and Smith & Nephew; and owns stocks in Gauss surgical and Intelijoint. Ran Schwarzkopf also receives research support from Smith & Nephew.

Ethical approval

This study has obtained all required IRB and ethical approval at our institution.

Informed consent

This study is a retrospective review in which patients were subject to their normal standard of care. No individual data is included within this study.

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Zak, S.G., Tang, A., Pivec, R. et al. The effects of tourniquet on cement penetration in total knee arthroplasty. Arch Orthop Trauma Surg 143, 2877–2884 (2023). https://doi.org/10.1007/s00402-022-04470-w

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  • DOI: https://doi.org/10.1007/s00402-022-04470-w

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