Skip to main content

Advertisement

SpringerLink
Log in

Tourniquet use in primary total knee arthroplasty is associated with a hypercoagulable status: a prospective thromboelastography trial

  • Original Paper
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Study design

Prospective study.

Purpose

The main purpose of this study was to investigate whether the use of a tourniquet changes the blood coagulation state following primary total knee arthroplasty (TKA) by means of conventional coagulation tests and thromboelastography (TEG) analyses.

Methods

A total of 154 patients who underwent primary unilateral TKA from January 2018 to October 2020 were enrolled. Seventy-nine patients were randomized into a tourniquet group, and 75 were randomized into a no-tourniquet group. Demographic data, surgical time, intra-operative blood loss, transfusion rate, and wound complications were collected. Complete blood count, conventional coagulation tests, and TEG were performed the day before surgery, one day after surgery, three days after surgery, and seven days after surgery. Lower extremity Doppler ultrasound was performed the day before surgery and seven days after surgery.

Results

The baseline characteristics of the patients were similar between the two groups. Hidden blood loss, transfusion rate, and wound complications were similar between the two groups, but the intra-operative blood loss of the tourniquet group was lower than that of the no-tourniquet group. The calculated total blood loss of the tourniquet group was higher than that of the no-tourniquet group. In terms of conventional coagulation tests and TEG, the tourniquet group had higher values of fibrin degradation products, D-dimer, maximum amplitude, and coagulation index (p < 0.001). The incidence of deep vein thrombosis (DVT) in the tourniquet group was higher than that in the no-tourniquet group (21.5% compared with 8%; p = 0.019).

Conclusion

The application of a tourniquet during TKA significantly increases the amount of calculated total blood loss and does not decrease the post-operative transfusion rate. Using a tourniquet in routine TKA exacerbates the early post-operative hypercoagulable status together with a higher incidence of below-knee asymptomatic DVT observed via conventional coagulation tests, TEG, and ultrasonic Doppler.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data availability

All data and materials completed during this study are included in this published article.

References

  1. Price AJ, Alvand A, Troelsen A, Katz JN, Hooper G, Gray A, Carr A, Beard D (2018) Knee replacement. Lancet 392(10158):1672–1682. https://doi.org/10.1016/S0140-6736(18)32344-4

    Article  PubMed  Google Scholar 

  2. Rosencher N, Kerkkamp HE, Macheras G, Munuera LM, Menichella G, Barton DM, Cremers S, Abraham IL (2003) OSTHEO Investigation. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion 43(4):459–469. https://doi.org/10.1046/j.1537-2995.2003.00348

  3. Alshryda S, Mason J, Vaghela M, Sarda P, Nargol A, Maheswaran S, Tulloch C, Anand S, Logishetty R, Stothart B, Hungin AP (2013) Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total knee replacement: a randomized controlled trial (TRANX-K). J Bone Joint Surg Am 95(21):1961–1968. https://doi.org/10.2106/jbjs.l.00907

    Article  PubMed  Google Scholar 

  4. Goel R, Rondon AJ, Sydnor K, Blevins K, O’Malley M, Purtill JJ, Austin MS (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(20):1821–1828. https://doi.org/10.2106/jbjs.19.00146

  5. Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L (2014) The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 9(1):13. https://doi.org/10.1186/1749-799x-9-13

    Article  PubMed  PubMed Central  Google Scholar 

  6. 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(10):1469–1476. https://doi.org/10.1007/s00402-014-2056-y

    Article  PubMed  Google Scholar 

  7. Zhao HY, Yeersheng R, Kang XW, Xia YY, Kang PD, Wang WJ (2020) The effect of tourniquet uses on total blood loss, early function, and pain after primary total knee arthroplasty: a prospective, randomized controlled trial. Bone Joint Res 9(6):322–332. https://doi.org/10.1302/2046-3758.96.bjr-2019-0180.r3

    Article  PubMed  PubMed Central  Google Scholar 

  8. 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 Arthroplasty 27(3):331–340. https://doi.org/10.1016/j.arth.2011.04.046

    Article  PubMed  Google Scholar 

  9. Alexandersson M, Wang EY, Eriksson S (2019) A small difference in recovery between total knee arthroplasty with and without tourniquet use the first 3 months after surgery: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 27(4):1035–1042. https://doi.org/10.1007/s00167-018-5196-8

    Article  PubMed  Google Scholar 

  10. Arthur JR, Spangehl MJ (2019) Tourniquet use in total knee arthroplasty. J Knee Surg 32(8):719–729. https://doi.org/10.1055/s-0039-1681035

    Article  PubMed  Google Scholar 

  11. Cai DF, Fan QH, Zhong HH, Peng S, Song H (2019) The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: a meta-analysis. J Orthop Surg Res 14(1):348. https://doi.org/10.1186/s13018-019-1422-4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Xu H, Yang J, Xie J, Huang Z, Huang Q, Cao G, Pei F (2020) Tourniquet use in routine primary total knee arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a real-world study. BMC Musculoskelet Disord 21(1):620. https://doi.org/10.1186/s12891-020-03623-5

    Article  PubMed  PubMed Central  Google Scholar 

  13. Westrich GH, Sculco TP, Prophylaxis against deep venous thrombosis after total knee arthroplasty, (1996) Pneumatic plantar compression and aspirin compared with aspirin alone. J Bone Joint Surg Am 78(6):826–834. https://doi.org/10.2106/00004623-199606000-00004

    Article  CAS  PubMed  Google Scholar 

  14. Stulberg BN, Insall JN, Williams GW, Ghelman B (1984) Deep-vein thrombosis following total knee replacement. An analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg Am 66(2):194–201.

  15. Mori N, Kimura S, Onodera T, Iwasaki N, Nakagawa I, Masuda T (2016) Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: A prospective, randomized study. Knee 23(5):887–889. https://doi.org/10.1016/j.knee.2016.02.007

    Article  PubMed  Google Scholar 

  16. Doran CM, Woolley T, Midwinter MJ (2010) Feasibility of using rotational thromboelastometry to assess coagulation status of combat casualties in a deployed setting. J Trauma 69(Suppl 1):S40–S48. https://doi.org/10.1097/ta.0b013e3181e4257b

    Article  PubMed  Google Scholar 

  17. Huang J, Zhang P, Wang D (2018) A study of coagulation changes at early stage after total knee arthroplasty. J Knee Surg 31(9):913–918. https://doi.org/10.1055/s-0038-1625957

    Article  PubMed  Google Scholar 

  18. Wang C, Liu Q, Sun L, Dai G (2019) Application of thrombelastography in primary total knee and total hip replacement: a prospective 87 patients study. Blood Coagul Fibrinolysis 30(6):281–290. https://doi.org/10.1097/mbc.0000000000000839

    Article  PubMed  Google Scholar 

  19. Wang J, Zhu HL, Shi ZJ, Zhang Y (2018) The application of thromboelastography in understanding and management of ecchymosis after total knee arthroplasty. J Arthroplasty 33(12):3754–3758. https://doi.org/10.1016/j.arth.2018.08.024

    Article  PubMed  Google Scholar 

  20. Hagemo JS, Næss PA, Johansson P, Windeløv NA, Cohen MJ, Røislien J, Brohi K, Heier HE, Hestnes M, Gaarder C (2013) Evaluation of TEG(®) and RoTEM(®) inter-changeability in trauma patients. Injury 44(5):600–605. https://doi.org/10.1016/j.injury.2012.11.016

    Article  PubMed  Google Scholar 

  21. Ruan RX, Bai CW, Zhang L, Huang CR, Pan S, Zhang XC, Zhu ZY, Zheng X, Guo KJ (2020) Does subcutaneous administration of recombinant human erythropoietin increase thrombotic events in total hip arthroplasty? A prospective thrombelastography analysis. J Orthop Surg Res 15(1):546. https://doi.org/10.1186/s13018-020-02083-w

    Article  PubMed  PubMed Central  Google Scholar 

  22. Zhang XC, Sun MJ, Pan S, Rui M, Zhao FC, Zha GC, Pang Y, Zheng X, Guo KJ (2020) Intravenous administration of tranexamic acid in total hip arthroplasty does not change the blood coagulopathy: a prospective thrombelastography analysis. J Orthop Surg (Hong Kong) 28(3):2309499020959516. https://doi.org/10.1177/2309499020959516

    Article  Google Scholar 

  23. Karon BS (2014) Why is everyone so excited about thromboelastrography (TEG)? Clin Chim Acta 436:143–148. https://doi.org/10.1016/j.cca.2014.05.013

    Article  CAS  PubMed  Google Scholar 

  24. Cotton BA, Faz G, Hatch QM, Radwan ZA, Podbielski J, Wade C, Kozar RA, Holcomb JB (2011) Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma 71(2):407–414. https://doi.org/10.1097/ta.0b013e31821e1bf0

    Article  PubMed  Google Scholar 

  25. Cohen AT, Alikhan R, Arcelus JI, Bergmann JF, Haas S, Merli GJ, Spyropoulos AC, Tapson VF, Turpie AG (2005) Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost 94(4):750–759

    PubMed  Google Scholar 

  26. Buckner TW, Leavitt AD, Ragni M, Kempton CL, Eyster ME, Cuker A, Lentz SR, Ducore J, Leissinger C, Wang M, Key NS (2016) Prospective, multicenter study of postoperative deep-vein thrombosis in patients with haemophilia undergoing major orthopaedic surgery. Thromb Haemost 116(1):42–49. https://doi.org/10.1160/th15-10-0802

    Article  PubMed  Google Scholar 

  27. Hart A, Khalil JA, Carli A, Huk O, Zukor D, Antoniou J (2014) Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. J Bone Joint Surg Am 96(23):1945–1951. https://doi.org/10.2106/jbjs.n.00077

  28. Fitzgibbons PG, Digiovanni C, Hares S, Akelman E (2012) Safe tourniquet use: a review of the evidence. J Am Acad Orthop Surg 20(5):310–319. https://doi.org/10.5435/jaaos-20-05-310

    Article  PubMed  Google Scholar 

  29. Schnettler T, Papillon N, Rees H (2017) Use of a tourniquet in total knee arthroplasty causes a paradoxical increase in total blood loss. J Bone Joint Surg Am 99(16):1331–1336. https://doi.org/10.2106/jbjs.16.00750

    Article  PubMed  Google Scholar 

  30. Mardian S, Matziolis G, Schwabe P (2015) Influence of wound drainage in primary total knee arthroplasty without tourniquet. Int Orthop 39(3):435–440. https://doi.org/10.1007/s00264-014-2498-4

    Article  PubMed  Google Scholar 

  31. Zhou K, Wang H, Li J, Wang D, Zhou Z, Pei F (2017) Non-drainage versus drainage in tourniquet-free knee arthroplasty: a prospective trial. ANZ J Surg 87(12):1048–1052. https://doi.org/10.1111/ans.14183

    Article  PubMed  Google Scholar 

  32. Kaufman JA, Kinney TB, Streiff MB, Sing RF, Proctor MC, Becker D, Cipolle M, Comerota AJ, Millward SF, Rogers FB, Sacks D, Venbrux AC (2006) Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference. J Vasc Interv Radiol 17(3):449–459. https://doi.org/10.1097/01.rvi.0000203418-39769.0d

    Article  PubMed  Google Scholar 

  33. Gross JB (1983) Estimating allowable blood loss: corrected for dilution. Anesthesiology 58(3):277–280. https://doi.org/10.1097/00000542-198303000-00016

    Article  CAS  PubMed  Google Scholar 

  34. Sehat KR, Evans RL, Newman JH (2004) Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 86(4):561–565.

  35. Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M (2000) Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res 371:169–177. https://doi.org/10.1097/00003086-200002000-00021

    Article  Google Scholar 

  36. Smith TO, Hing CB (2010) Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review Knee 17(2):141–147. https://doi.org/10.1016/j.knee.2009.06.007

    Article  PubMed  Google Scholar 

  37. Hartert H (1948) Blutgerinnung studien mit der thrombelastographie, einem neuen untersuchung- sverfahren. Klin Wochenschr 26:557–583

    Article  Google Scholar 

  38. Samuelson BT, Cuker A, Siegal DM, Crowther M, Garcia DA (2017) Laboratory assessment of the anticoagulant activity of direct oral anticoagulants: a systematic review. Chest 151(1):127–138. https://doi.org/10.1016/j.chest.2016.08.1462

    Article  PubMed  Google Scholar 

  39. Gary JL, Schneider PS, Galpin M, Radwan Z, Munz JW, Achor TS, Prasarn ML, Cotton BA (2016) Can thrombelastography predict venous thromboembolic events in patients with severe extremity trauma? J Orthop Trauma 30(6):294–298. https://doi.org/10.1097/bot.0000000000000523

    Article  PubMed  Google Scholar 

  40. Schiff RL, Kahn SR, Shrier I, Strulovitch C, Hammouda W, Cohen E, Zukor D (2005) Identifying orthopedic patients at high risk for venous thromboembolism despite thromboprophylaxis. Chest 128(5):3364–3371. https://doi.org/10.1378/chest.128.5.336

    Article  PubMed  Google Scholar 

Download references

Funding

This study was supported by the National Natural Science Foundation of China (81902244), the Natural Science Foundation of Jiangsu Province (BK20201154), Jiangsu Provincial Medical Youth Talent (QNRC2016801), and Xuzhou Science and Technology Innovation Project (KC19063).

Author information

Authors and Affiliations

  1. Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road West, Xuzhou, 221006, People’s Republic of China

    Chao-Ran Huang, Sheng Pan, Zheng Li, Ru-Xin Ruan, Wang-Yi Jin, Xing-Chen Zhang, Yong Pang, Kai-Jin Guo & Xin Zheng

  2. Department of Orthopaedics, Zhujiang Hospital of Southern Medical University, 253 Gongye Avenue, Guangzhou, 510282, People’s Republic of China

    Xin Zheng

Authors
  1. Chao-Ran Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sheng Pan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Zheng Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ru-Xin Ruan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wang-Yi Jin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Xing-Chen Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yong Pang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Kai-Jin Guo
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Xin Zheng
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Chao-Ran Huang, Sheng Pan, Kai-Jin Guo, and Xin Zheng designed the study and drafted the manuscript. Zheng Li, Ru-Xin Ruan, Wang-Yi Jin, Xing-Chen Zhang, and Yong Pang performed the data collection and the statistical analysis. Kai-Jin Guo and Xin Zheng contributed equally to this work and should be considered equal.

Corresponding authors

Correspondence to Kai-Jin Guo or Xin Zheng.

Ethics declarations

Ethical approval

This trial was approved by the ethical standards of Ethics Committee of the Affiliated Hospital of Xuzhou Medical University and in accordance with the 1964 Helsinki Declaration and its later amendments.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

All authors have read and approved to publish the final manuscript.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huang, CR., Pan, S., Li, Z. et al. Tourniquet use in primary total knee arthroplasty is associated with a hypercoagulable status: a prospective thromboelastography trial. International Orthopaedics (SICOT) 45, 3091–3100 (2021). https://doi.org/10.1007/s00264-021-05126-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-021-05126-x

Keywords

Search

Navigation