Abstract
Purpose
The optimal timing of pneumatic lower limb tourniquet application during primary elective total knee arthroplasty surgery (TKA) is a matter of debate. Most previous reports have failed to show significant differences between different tourniquet timings. The aim of the work was to determine how three strategies of lower limb pneumatic tourniquet application affect the outcome for TKA patients.
Methods
Fortythree patients who undergo TKA were randomized into one of the three groups, and 36 of these patients completed the study. The tourniquet was inflated just before incision and deflated after the hardening of the cement for twelve patients (Group 1), it was inflated just before cement application and deflated after its hardening for another twelve patients (Group 2), and it was inflated before incision and deflated after the last suture of the skin for a further twelve patients (Group 3). Fittodischarge criteria and six methods for calculating estimated blood loss were used.
Results
The estimated blood loss in Group 1 was lower than in Group 2, as determined by six methods of calculation (p < 0.05). Estimated blood loss in Group 3 was lower than in Group 2, as determined by one method (p = 0.050). The mobilization performance in Group 1 was better than in Group 2 (p = 0.023) and in Group 3 (p = 0.033). Group 1 was better fit to discharge than Group 3 (p = 0.030).
Conclusions
Inflation of an automatic pneumatic lower limb tourniquet before skin incision and its deflation after hardening of cement tends to give better outcomes in TKA patients during six postoperative days. The estimated blood loss was highest when the tourniquet was inflated just before cement application and deflated after its hardening.
Level of evidence
II.
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Acknowledgments
The project was supported by an ESA Research Grant 2009.
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Appendix
Appendix
Estimated blood loss: loss of blood volume and red cell mass
Estimated loss of blood volume
The six methods used to estimate blood loss were the following:

1.
‘Classic’ formula (version 1):
$$ {\text{BVL}} = {\text{BV}} \cdot ({\text{Hb}}_{\text{i}} \cdot {\text{Hb}}_{\text{f}}^{  1} )  {\text{BV}} $$(1)where BV is the normal BV calculated by Nadler’s formula.

2.
‘Classic’ formula (version 2):
$$ {\text{BVL}} = {\text{BV}} \cdot ({\text{Hb}}_{\text{i}} \cdot {\text{Hb}}_{\text{f}}^{  1} )  {\text{BV}} $$(2)where BV is the normal BV calculated by the formula recommended by the International Council for Standardization in Haematology.

3.
Modified Gross formula (version 1):
$$ {\text{BVL}} = {\text{BV}} \cdot \left( {{\text{Hct}}_{\text{i}}  {\text{Hct}}_{\text{f}} } \right) \cdot {\text{Hct}}_{\text{m}}^{  1} $$(3)where BV is the normal BV calculated by Nadler’s formula.

4.
Modified Gross formula (version 2):
$$ {\text{BVL}} = {\text{BV}} \cdot \left( {{\text{Hct}}_{\text{i}}  {\text{Hct}}_{\text{f}} } \right) \cdot {\text{Hct}}_{\text{m}}^{  1} $$(4)where BV is the normal BV calculated by the formula recommended by the International Council for Standardization in Haematology.

5.
Shander’s modification of the Gross formula (version 1):
$$ {\text{BVL}} = {\text{BV}} \cdot \left( {{\text{Hct}}_{\text{i}}  {\text{Hct}}_{\text{f}} } \right) \cdot \left( { 3 {\text{Hct}}_{\text{m}} } \right) $$(5)where BV is the normal BV calculated by Nadler’s formula.

6.
Shander’s modification of the Gross formula (version 2):
$$ {\text{BVL}} = {\text{BV}} \cdot \left( {{\text{Hct}}_{\text{i}}  {\text{Hct}}_{\text{f}} } \right) \cdot \left( { 3 {\text{Hct}}_{\text{m}} } \right) $$(6)where BV is the normal BV calculated by the formula recommended by the International Council for Standardization in Haematology.Hb _{ i } initial Hb, Hb _{ f } final Hb, Hct _{ i } initial Hct, Hct _{ f } final Hct, Hct _{ m } mean Hct.
Estimated normal blood volume

1.
Nadler’s formula:
$$ {\text{BV}} = {\text{kl}} \times {\text{height}}\, ( {\text{m)}}^{ 3} + {\text{k2}} \times {\text{weight}}\, ( {\text{kg)}} + {\text{k3}} $$(7)where BV is the normal blood volume, kl = 0.3669, k2 = 0.03219, k3 = 0.6041 for men, and kl = 0.3561, k2 = 0.03308, k3 = 0.1833 for women.Thus, BV for males is calculated as follows:
$$ {\text{BV}}_{\text{male}} = 0.3669 \cdot H({\text{m}})^{3} + 0.03219 \cdot W\,({\text{kg}}) + 0.6041 $$(7a)and BV for females is calculated as follows:
$$ {\text{BV}}_{\text{female}} = 0.3561 \cdot H\,({\text{m}})^{3} + 0.03308 \cdot W\,({\text{kg}}) + 0.1833 $$(7b) 
2.
Formula recommended by the International Council for Standardization in Haematology:
$$ {\text{BV}} = {\text{PV}} + {\text{RCV}} $$(8)
Formula for normal blood volume in males:
$$ \begin{aligned} {\text{BV}} & = {\text{PV}} + {\text{RCV}} = \left( {W^{0. 4 2 5} \times \, H^{0. 7 2 5} } \right) \times 0.00 7 1 8 4\times 3 ,0 6 4\, ( {\text{ml}}/{\text{m}}^{ 2} ) 8 2 5\\ {\text{PV}} & = {\text{BSA}} \times 1 , 5 7 8\\ {\text{RCV}} & = {\text{BSA}} \times 1 , 4 8 6 8 2 5\\ \end{aligned} $$(8a)where BV is the normal blood volume, PV is the normal plasma volume, RCV is the normal red cell volume, BSA is the body surface area in m^{2}, W is the body weight in kilograms, and H is the body height in cm.

Formula for normal blood volume in females:
$$ \begin{aligned} {\text{BV}} & = {\text{PV}} + {\text{RCV}} = \left( {W^{0. 4 2 5} \times \, H^{0. 7 2 5} } \right) \times 0.00 7 1 8 4\times 2 , 2 1 7+ {\text{age}}\, ( {\text{years)}} \times 1.0 6\\ {\text{PV}} & = {\text{BSA}} \times 1 , 3 9 5\\ {\text{RCV}} & = {\text{BSA}} \times 8 2 2+ {\text{age}}\, ( {\text{years)}} \times 1.0 6\\ \end{aligned} $$(8b) 
Formula for calculating body surface area (BSA) in both genders:
$$ {\text{BSA}} = (W^{0. 4 2 5} \times H^{0. 7 2 5} ) \times 0.00 7 1 8 4 $$where BSA is the body surface area in m^{2}, W is the body weight in kilograms, and H is the body height in cm.

Estimated loss of red cell mass (volume)
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Kvederas, G., Porvaneckas, N., Andrijauskas, A. et al. A randomized doubleblind clinical trial of tourniquet application strategies for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21, 2790–2799 (2013). https://doi.org/10.1007/s0016701222211
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DOI: https://doi.org/10.1007/s0016701222211