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

Abstract

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.

Graphic abstract

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References

  1. 1.

    Ahmed, I., Chawla, A., Underwood, M., Price, A., Metcalfe, A., Hutchinson, C., et al. (2021). Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. The Bone & Joint Journal, 103B(5), 830–839.

    Article  Google Scholar 

  2. 2.

    Mylod, J. A., France, M. P., Muser, D. E., & Parsons, J. R. (1990). Perioperative blood loss associated with total knee arthroplasty. A comparison of procedures performed with and without cementing. The Journal of Bone and Joint Surgery, 72(7), 1010–1012.

    Article  Google Scholar 

  3. 3.

    Hernandez, A. J., Almeida, A. M., Favaro, E., & Sguizzato, G. T. (2012). The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty. Clinics (São Paulo), 67(9), 1053–1057.

    Article  Google Scholar 

  4. 4.

    Fukuda, A., Hasegawa, M., Kato, K., Shi, D., Sudo, A., & Uchida, A. (2007). Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty. Archives of Orthopaedic and Trauma Surgery, 127(8), 671–675.

    Article  Google Scholar 

  5. 5.

    Langkamer, V. G. (2001). Local vascular complications after knee replacement: a review with illustrative case reports. The Knee, 8(4), 259–264.

    CAS  Article  Google Scholar 

  6. 6.

    Rush, J., Vidovich, J., & Johnson, M. (1987). Arterial complications of total knee replacement. The Australian experience. Journal of Bone and Joint Surgery, 69B, 400.

    Article  Google Scholar 

  7. 7.

    Dua, A., Zepeda, R., Hernanez, F. C., Igbadumhe, A. A., & Desai, S. S. (2015). The national incidence of iatrogenic popliteal artery injury during total knee replacement. Vascular, 23(5), 455–458.

    Article  Google Scholar 

  8. 8.

    Ammori, M. B., Evans, A. R., & Mclain, A. D. (2016). Popliteal artery pseudoaneurysm after total knee arthroplasty. The Journal of Arthroplasty., 31(9), 2004–2007.

    Article  Google Scholar 

  9. 9.

    Arthur, J., & Spangehl, M. (2019). Tourniquet use in total knee arthroplasty. Journal of Knee Surgery. https://doi.org/10.1055/s-0039-1681035

    Article  PubMed  Google Scholar 

  10. 10.

    Jawhar, A., Stetzelberger, V., Kollowa, K., & Obertacke, U. (2019). Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 27(7), 2071–2081.

    Article  Google Scholar 

  11. 11.

    Tindall, A., Shetty, A., James, K., Middleton, A., & Fernando, K. (2006). Prevalence and surgical significance of a high-origin anterior tibial artery. Journal of Orthopaedic Surgery, 14(1), 13–16.

    CAS  Article  Google Scholar 

  12. 12.

    Tai, T.-W., Lin, C.-J., Jou, I.-M., Chang, C.-W., Lai, K.-A., & Yang, C.-Y. (2011). Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 19(7), 1121–1130.

    Article  Google Scholar 

  13. 13.

    Ali Algadiem, E., Aleisa, A., Alsubaie, H., Buhlaiqah, N., Algadeeb, J., & Alsneini, H. (2016). Blood loss estimation using gauze visual analogue. Trauma Monthly. https://doi.org/10.5812/traumamon.34131

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Insall, J. N., Dorr, L. D., Scott, R. D., & Scott, W. N. (1989). Rationale of the Knee Society clinical rating system. Clinical Orthopaedics and Related Research, 248, 13–14.

    Google Scholar 

  15. 15.

    Bin Abd Razak, H., Binte Abd Razak, N., & Tan, H. (2017). Prevalence of venous thromboembolic events is low in asians after total knee arthroplasty without chemoprophylaxis. The Journal of Arthroplasty, 32(3), 974–979.

    Article  Google Scholar 

  16. 16.

    Curtis, G., Jawad, M., Samuel, L., George, J., Higuera-Rueda, C., Little, B., et al. (2019). Incidence, causes, and timing of 30-day readmission following total knee arthroplasty. The Journal of Arthroplasty, 34(11), 2632–2636.

    Article  Google Scholar 

  17. 17.

    Hasanain, M., Apostu, D., Alrefaee, A., & Tarabichi, S. (2018). Comparing the effect of tourniquet vs tourniquet-less in simultaneous bilateral total knee arthroplasties. The Journal of Arthroplasty, 33(7), 2119–2124.

    Article  Google Scholar 

  18. 18.

    Liu, P., Li, D., Zhang, Y., Lu, Q., Ma, L., Bao, X., et al. (2017). Effects of unilateral tourniquet used in patients undergoing simultaneous bilateral total knee arthroplasty. Orthopaedic Surgery, 9(2), 180–185.

    Article  Google Scholar 

  19. 19.

    Song, K., Xu, Z., Rong, Z., Yang, X., Yao, Y., Shen, Y., et al. (2016). The incidence of venous thromboembolism following total knee arthroplasty. Blood Coagulation & Fibrinolysis, 27(3), 266–269.

    Article  Google Scholar 

  20. 20.

    Mittal, R., Ko, V., Adie, S., Naylor, J., Dave, J., Dave, C., et al. (2012). Tourniquet application only during cement fixation in total knee arthroplasty: a double-blind, randomised controlled trial: RCT tourniquet during cementing in TKA. ANZ Journal of Surgery, 82(6), 428–433.

    Article  Google Scholar 

  21. 21.

    Goel, R., Rondon, A., Sydnor, K., Blevins, K., O’Malley, M., Purtill, J., et al. (2019). Tourniquet use does not affect functional outcomes or pain after total knee arthroplasty. The Journal of Bone and Joint Surgery, 101(20), 1821–1828.

    Article  Google Scholar 

  22. 22.

    Wang, K., Ni, S., Li, Z., Zhong, Q., Li, R., Li, H., et al. (2017). The effects of tourniquet use in total knee arthroplasty: a randomised, controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy, 25(9), 2849–2857.

    Article  Google Scholar 

  23. 23.

    Sharma, K., Haque, M., & Mansur, D. (2012). Bilateral high-origin anterior tibial arteries and its clinical importance. Kathmandu University Medical Journal, 10(1), 83–84.

    Article  Google Scholar 

  24. 24.

    Statz, J., Ledford, C., Chalmers, B., Taunton, M., Mabry, T., & Trousdale, R. (2018). Geniculate artery injury during primary total knee arthroplasty. American Journal of Orthopedics. https://doi.org/10.1278/ajo.2018.0097

    Article  PubMed  Google Scholar 

  25. 25.

    Padegimas, E. M., Levicoff, E. A., McGinley, A. D., Sharkey, P. F., & Good, R. P. (2016). Vascular complications after total knee arthroplasty—a single institutional experience. The Journal of Arthroplasty, 31(7), 1583–1588.

    Article  Google Scholar 

  26. 26.

    Tarwala, R., Dorr, L. D., Gilbert, P. K., Wan, Z., & Long, W. T. (2014). Tourniquet use during cementation only during total knee arthroplasty: a randomised trial. Clinical Orthopaedics and Related Research, 472(1), 6.

    Article  Google Scholar 

  27. 27.

    Liu, Y., Si, H., Zeng, Y., Li, M., Xie, H., & Shen, B. (2019). More pain and slower functional recovery when a tourniquet is used during total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 28(6), 1842–1860.

    Article  Google Scholar 

  28. 28.

    Burns, L., Ritvo, S., Ferguson, M., Clark, H., & Seltzer, Z. (2015). Katz J (2015) Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. Journal of Pain Research, 8, 21–32.

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    Nishiguchi, M., Takamura, N., Abe, Y., Kono, M., Shindo, H., & Aoyagi, K. (2005). Pilot study on the use of tourniquet: a risk factor for pulmonary thromboembolism after total knee arthroplasty? Thrombosis Research, 115(4), 271–276.

    CAS  Article  Google Scholar 

  30. 30.

    Rames, R. D., Haynes, J., Hellman, M., Barrack, T., & Barrack, R. (2019). Impact of tourniquet strategy on perioperative results of modern TKA. Journal of Knee Surgery. https://doi.org/10.1055/s-0039-1688919

    Article  PubMed  Google Scholar 

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Affiliations

Authors

Contributions

JN did preoperative evaluation, enrolled patients, randomisation, participated in the design of the study, performed statistical analyses, and wrote the manuscript. AE and SB coordinated and did the surgeries and contributed in writing the manuscript. AE and SB have reviewed and analysed the data and attest to the integrity of the original data reported in this manuscript. PKG did the preoperative and postoperative radiological evaluation of the patients in this study.

Corresponding author

Correspondence to Abhay Elhence.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Ethics Approval

The study was performed only after the approval of the Research Ethics Committee (AIIMS/IEC/2018/475).

Informed Consent

For this study informed consent was obtainted from the participants.

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Netaji, J., Banerjee, S., Garg, P.K. et al. Reappraisal of Limited Duration Tourniquet in Total Knee Arthroplasty: A Double-Blinded RCT. JOIO 55, 1186–1194 (2021). https://doi.org/10.1007/s43465-021-00506-2

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Keywords

  • Total knee arthroplasty
  • Tourniquet
  • DVT
  • Arterial thrombosis