There is no consensus on the position of the knee joint while performing wound closure after total knee arthroplasty (TKA). Further, there are no studies focusing on the association between early functional outcomes and different wound closure strategies. Therefore, we investigated the effects of tourniquet and knee position during wound closure on early recovery of range of motion (ROM) after primary TKA. To our knowledge, this is the first study to evaluate the influence of both tourniquet and knee position during wound closure in primary TKA.
One hundred-twenty eligible patients were consecutively enrolled in this study and randomly divided into four groups according to wound closure strategy. Wound closure was either performed with the knee in flexion at 90° or in full extension, with the combination of an inflated or deflated tourniquet. Visual analogue score (VAS), knee ROM, ROM recovery, knee society score (KSS), and wound complications were evaluated in the early postoperative period.
After the first postoperative week, ROM recovery in the group with knee in extension and inflated tourniquet was significantly lesser than the two groups with deflated tourniquets. Between the first and fourth postoperative weeks, ROM recovery in the group with knee inflection and deflated tourniquet was significantly higher than the two groups with knee in extension. After the first postoperative week, the visual analog score (VAS) for pain in the group with knee inflection and deflated tourniquet was significantly lesser than the two groups with inflated tourniquets. The differences in the outcomes between the four groups were not significant after the fourth postoperative week. The incidence of wound complications and KSS were not significantly different between the four groups.
Following TKA, wound closure with the knee in flexion and after deflating the tourniquet significantly decreased postoperative pain and promoted the recovery of ROM in the early postoperative period.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Zhou Z, Yew KS, Arul E, Chin PL, Tay KJ, Lo NN, Chia SL, Yeo SJ (2015) Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23:1729–1733
Salmon P, Hall GM, Peerbhoy D, Shenkin A, Parker C (2001) Recovery from hip and knee arthroplasty: patients’ perspective on pain, function, quality of life, and well-being up to 6 months postoperatively. Arch Phys Med Rehabil 82:360–366
Van Egmond JC, Verburg H, Mathijssen NM (2015) The first 6 weeks of recovery after total knee arthroplasty with fast track. Acta Orthop 86:708–713
Pulido L, Parvizi J, Macgibeny M, Sharkey PF, Purtill JJ, Rothman RH, Hozack WJ (2008) In hospital complications after total joint arthroplasty. J Arthroplasty 23:139–145
Mears SC, Edwards PK, Barnes CL (2016) How to decrease length of hospital stay after total knee replacement. J Surg Orthop Adv 25:2–7
Waimann CA, Fernandez-Mazarambroz RJ, Cantor SB, Lopez-Olivo MA, Zhanq H, Landon GC, Siff SJ, Suarez-Almazor ME (2014) Cost-effectiveness of total knee replacement: a prospective cohort study. Arthritis Care Res 66:592–599
Schwarzkopf R, Ho J, Quinn JR, Snir N, Mukamel D (2016) Factors influencing discharge destination after total knee arthroplasty: a database analysis. Geriatr Orthop Surg Rehabil 7:95–99
Dennis DA, Komistek RD, Scuderi GR, Zingde S (2007) Factors affecting flexion after total knee arthroplasty. Clin Orthop Relat Res 464:53–60
Bade MJ, Kittelson JM, Kohrt WM, Stevens-Lapsley JE (2014) Predicting functional performance and range of motion outcomes after total knee arthroplasty. Am J Phys Med Rehabil 93:579–585
Dennis DA, Heekin RD, Clark CR, Murphy JA, O’Dell TL, Dwyer KA (2013) Effect of implant design on knee flexion. J Arthroplast 28:429–438
Chiu KY, Ng TP, Tang WM, Yau WM (2002) Review article: knee flexion after total knee arthroplasty. J Orthop Surg 10:194–202
Hoogeboom TJ, van Meeteren NL, Schank K, Kim RH, Miner T, Stevens-Lapsley JE (2015) Risk factors for delayed inpatient functional recovery after total knee arthroplasty. Biomed Res Int 2015:167643 Epub 2015 Apr 16
Liu D, Graham D, Gillies K, Gilles RM (2014) Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. Knee Surg Relat Res 26:207–213
King TV, Kish G, Eberhart RE, Holzaepfel JL (1992) The ‘genuflex’ skin closure for total knee arthroplasty. Orthopedics 15:1057–1058
Komatsu T, Ishibashi Y, Otsuka H, Naqao A, Toh S (2003) The effect of surgical approaches and tourniquet application on patellofemoral tracking in total knee arthroplasty. J Arthroplast 18:308–312
Vince KG (2012) Wound closure: healing the collateral damage. J Bone Jt Surg Br 94(11 Suppl A):126–133
Zan PF, Yang Y, Fu D, Yu X, Li GD (2015) Releasing of tourniquet before wound closure or not in total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplast 30:31–37
Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the knee society clinical rating system. Clin Orthop Relat Res 248:13–14
Na YG, Bamne AB, Won HH, Kim TK (2015) After early release of tourniquet in total knee arthroplasty, should it be reinflated or kept deflated? A randomized trial. Knee Surg Sports Traumatol Arthrosc (Epub ahead of print)
Masri BA, Laskin RS, Windsor RE, Haas SB (1996) Knee closure in total knee replacement: a randomized prospective trial. Clin Orthop Relat Res 331:81–86
Smith TO, Davies L, Hing CB (2010) Wound closure in flexion versus extension following total knee arthroplasty: a systematic review. Acta Orthop Belg 76:298–306
Motififard M, Heidari M, Nemati A (2016) No difference between wound closure in extension or flexion for range of motion following total knee arthroplasty: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 24:74–78
Kömürcü E, Yüksel HY, Ersöz M, Aktekin CN, Hapa O, Çelebi L, Akbal A, Biçimoğlu A (2014) Effect of surgical closing in total knee arthroplasty at flexion or extension: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 22:3067–3073
Emerson RH Jr, Ayers C, Head WC, Higgins LL (1996) Surgical closing in primary total knee arthroplasties: flexion versus extension. Clin Orthop Relat Res 331:74–80
Cerciello S, Morris BJ, Lustig S, Corona K, Visonà E, Maccauro G, Neyret P (2016) The role of wound closure in total knee arthroplasty: a systematic review on knee position. Knee Surg Sports Traumatol Arthrosc
Matsumoto T, Tsumura N, Kubo S, Shiba R, Kurosaka M, Yoshiya S (2005) Influence of hip position on knee flexion angle in patients undergoing total knee arthroplasty. J Arthroplast 669–673
Robertsson O, Ranstam J, Sundberg M, W-Dahl, Lidgren L (2014) The Swedish Knee Arthroplasty Register: a review. Bone Jt Res 3:217–222
Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P (2012) A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplast 27:331–340
Rathod P, Deshmukh A, Robinson J, Greiz M, Ranawat A, Rodriguez J (2015) Does tourniquet time in primary total knee arthroplasty influence clinical recovery? J Knee Surg 28:335–342
Kvederas G, Porvaneckas N, Andrijauskas A, Svensen CH, Ivaskevicius J, Mazunaitis J, Marmaite U, Andrijauskas P (2013) A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21:2790–2799
Rama KR, Apsingi S, Poovali S, Jetti A (2007) Timing of tourniquet release in knee arthroplasty: meta-analysis of randomized, controlled trials. J Bone Jt Surg Am 89:699–705
Chang CW, Lan SM, Tai TW, Lai KA, Yanq CY (2012) An effective method to reduce ischemia time during total knee arthroplasty. J Formos Med Assoc 111:19–23
Heller S, Chen A, Restrepo C, Albert E, Hozack WJ (2015) Tourniquet release prior to dressing application reduces blistering following total knee arthroplasty. J Arthroplast 30:1207–1210
Huang ZY, Pei FX, Ma J, Yang J, Zhou ZK, Kang PD, Shen B (2014) Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial. Arch Orthop Trauma Surg 134:561–570
Dreyer HC (2016) Tourniquet use during knee replacement surgery may contribute to muscle atrophy in older adults. Exerc Sport Sci Rev 44:61–70
Dennis DA, Kittelson AJ, Yang CC, Miner TM, Kim RH, Stevens-Lapsley JE (2016) Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res 474:69–77
Plate JF, Seyler TM, Halvorson JJ, santago AC, Lanq JE (2014) Non-anatomical capsular closure of a standard parapatellar knee arthrotomy leads to patellar maltracking and decreased range of motion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 22:543–549
Wang S, Xia J, Wei Y, Wu J, Huang G (2014) Effect of the knee position during wound closure after total knee arthroplasty on early knee function recovery. J Orthop Surg Res 9:79
Husted H, Toftgaard Jensen T (2005) Influence of the pneumatic tourniquet on patella tracking in total knee arthroplasty: a prospective randomized study in 100 patients. J Arthroplast 20:694–697
Lotke PA, Faralli VJ, Orenstein EM, Ecker ML (1991) Blood loss after total knee replacement: effects of tourniquet release and continuous passive motion. J Bone Jt Surg Am 73:1037–1040
Huang Z, Ma J, Zhu Y, Pei F, Yang J, Zhou Z, Kang P, Shen B (2015) Timing of tourniquet release in total knee arthroplasty. Orthopedics 38:445–451
Yi S, Tan J, Chen C, Chen H, Huang W (2014) The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 134:1469–1476
Burkart BC, Bourne RB, Rorabeck CH, Kirk PG, Nott L (1994) The efficacy of tourniquet release in blood conservation after total knee arthroplasty. Clin Orthop Relat Res 299:147–152
Herald J, Cooper L, Machart F (2002) Tourniquet-induced restriction of the quadriceps muscle mechanism. Fact or fiction? J Bone Jt Surg Br 84:856–857
About this article
Cite this article
Şükür, E., Öztürkmen, Y., Akman, Y.E. et al. The effect of tourniquet and knee position during wound closure after total knee arthroplasty on early recovery of range of motion: a prospective, randomized study. Arch Orthop Trauma Surg 136, 1773–1780 (2016). https://doi.org/10.1007/s00402-016-2582-x