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Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

01-07-2019 | KNEE

Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty

Authors: Ahmed Jawhar, Vera Stetzelberger, Karl Kollowa, Udo Obertacke

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 7/2019

Abstract

Purpose

Poor scientific evidence exists on the issue of tourniquet application during total knee arthroplasty (TKA). It has been suggested that tourniquet application might improve interdigitation of the cement into the periprosthetic bones due to relatively dry surgical field. The hypothesis of the present study was that tourniquet use did not affect the periprosthetic bone cement penetration.

Methods

The single-centre, randomized, controlled trial included 86 patients undergoing primary TKA (Clinical-Trials.gov NCT02475603). All patients meeting the inclusion criteria were randomly assigned to the tourniquet (n = 43) or non-tourniquet (n = 43) group after obtaining a written informed consent. The cumulative bone cement penetration was radiologically measured in AP (seven zones) and lateral views (three zones) as defined by Knee Society Scoring System. Further parameters such as perioperative blood loss, soft tissue swelling, pain level/analgesic consumption, operative time, length of hospital stay (LOS) and complication rate were statistically compared between the groups.

Results

The cumulative bone cement penetration averaged 28.5 ± 1.7 mm in tourniquet versus 26.6 ± 1.6 mm in non-tourniquet groups (n.s.). The mean intraoperative blood loss was 250 ml higher in the non-tourniquet group (p = 0.0001). Patient-reported pre- to 6th-day post-operative reduction of the pain level was significantly higher in the non-tourniquet group (p = 0.003). The Morphine Equivalent Dose was higher in the Tourniquet group at discharge day (p = 0.02). Parameters such as total blood loss, soft tissue swelling, surgical time, LOS, and complication rates revealed similar results between the groups.

Conclusions

Tourniquet application did not influence the bone cement penetration significantly. Even though the intraoperative blood loss was reduced, the total blood loss was not affected significantly by tourniquet use. There was a tendency of higher post-operative pain and opioid analgesic requirement in the tourniquet group.

Level of evidence

American Society of Anesthesiologists (1963) New classification of physical status. Anesthesiology 111:24

Argenson JN, Parratte S, Ashour A, Saintmard B, Aubaniac JM (2012) The outcome of rotating-platform total knee arthroplasty with cement at a minimum of ten years of follow-up. J Bone Jt Surg Am 94:638–644CrossRef

Berry DJ, Bozic KJ (2010) Current practice patterns in primary hip and knee arthroplasty among members of the American Association of Hip and Knee Surgeons. J Arthroplasty 25:2–4CrossRefPubMed

Bert JM, McShane M (1998) Is it necessary to cement the tibial stem in cemented total knee arthroplasty? Clin Orthop Relat Res 356:73–78CrossRef

Bin Abd Razak HR, Tan HC (2014) The use of pneumatic tourniquets is safe in Asians undergoing total knee arthroplasty without anticoagulation. Knee 21:176–179CrossRefPubMed

Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383CrossRefPubMed

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

Ejaz A, Laursen AC, Kappel A, Laursen MB, Jakobsen T, Rasmussen S, Nielsen PT (2014) Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop 85:422–426CrossRefPubMedPubMedCentral

Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12

10.

Feng B, Weng X, Lin J, Jin J, Wang W, Qiu G (2013) Long-term follow-up of cemented fixed-bearing total knee arthroplasty in a Chinese population: a survival analysis of more than 10 years. J Arthroplasty 28:1701–1706CrossRefPubMed

11.

Foss NB, Kehlet H (2006) Hidden blood loss after surgery for hip fracture. J Bone Jt Surg Br 88:1053–1059CrossRef

12.

Gao FQ, Li ZJ, Zhang K, Sun W, Zhang H (2015) Four methods for calculating blood-loss after total knee arthroplasty. Chin Med J (Engl) 128:2856–2860CrossRef

13.

Good L, Peterson E, Lisander B (2003) Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 90:596–599CrossRefPubMed

14.

Harsten A, Bandholm T, Kehlet H, Toksvig-Larsen S (2015) Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty; a randomized controlled trial. Knee 22:126–130CrossRefPubMed

15.

Jiang FZ, Zhong HM, Hong YC, Zhao GF (2015) Use of a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Sci 20:110–123CrossRefPubMed

16.

Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502CrossRefPubMedPubMedCentral

17.

Kopec M, Milbrandt JC, Duellman T, Mangan D, Allan DG (2009) Effect of hand packing versus cement gun pressurization on cement mantle in total knee arthroplasty. Can J Surg 52:490–494PubMedPubMedCentral

18.

Kumar N, Yadav C, Singh S, Kumar A, Vaithlingam A, Yadav S (2015) Evaluation of pain in bilateral total knee replacement with and without tourniquet; a prospective randomized control trial. J Clin Orthop Trauma 6:85–88CrossRefPubMedPubMedCentral

19.

Ledin H, Aspenberg P, Good L (2012) Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthop 83:499–503CrossRefPubMedPubMedCentral

20.

Li X, Yin L, Chen ZY, Zhu L, Wang HL, Chen W, Yang G, Zhang YZ (2014) The effect of tourniquet use in total knee arthroplasty: grading the evidence through an updated meta-analysis of randomized, controlled trials. Eur J Orthop Surg Traumatol 24:973–986CrossRefPubMed

21.

Lisander B, Ivarsson I, Jacobsson SA (1998) Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery. Acta Anaesthesiol Scand 42:707–712CrossRefPubMed

22.

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 24:461–467CrossRefPubMed

23.

Molt M, Harsten A, Toksvig-Larsen S (2014) The effect of tourniquet use on fixation quality in cemented total knee arthroplasty a prospective randomized clinical controlled RSA trial. Knee 21:396–401CrossRefPubMed

24.

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 5:887–889CrossRef

25.

Nadler SB, Hidalgo JH, Bloch T (1962) Prediction of blood volume in normal human adults. Surgery 51:224–232PubMed

26.

Peters CL, Craig MA, Mohr RA, Bachus KN (2003) Tibial component fixation with cement: full- versus surface-cementation techniques. Clin Orthop Relat Res 409:158–168CrossRef

27.

Pfitzner T, von Roth P, Voerkelius N, Mayr H, Perka C, Hube R (2016) Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24:96–101CrossRefPubMed

28.

Ryd L, Albrektsson BE, Carlsson L, Dansgard F, Herberts P, Lindstrand A, Regner L, Toksvig-Larsen S (1995) Roentgen stereophotogrammetric analysis as a predictor of mechanical loosening of knee prostheses. J Bone Jt Surg Br 77:377–383CrossRef

29.

Schlegel UJ, Puschel K, Morlock MM, Nagel K (2014) An in vitro comparison of tibial tray cementation using gun pressurization or pulsed lavage. Int Orthop 38:967–971CrossRefPubMedPubMedCentral

30.

Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM (2002) Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res:7–13

31.

Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY (2011) Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 19:1121–1130CrossRefPubMed

32.

Vertullo CJ, Nagarajan M (2017) Is cement penetration in TKR reduced by not using a tourniquet during cementation? A single blinded, randomized trial. J Orthop Surg (Hong Kong) 25:2309499016684323CrossRef

33.

Wakankar HM, Nicholl JE, Koka R, D’Arcy JC (1999) The tourniquet in total knee arthroplasty. A prospective, randomised study. J Bone Jt Surg Br 81:30–33CrossRef

34.

Walker PS, Soudry M, Ewald FC, McVickar H (1984) Control of cement penetration in total knee arthroplasty. Clin Orthop Relat Res 185:155–164

35.

Wang K, Ni S, Li Z, Zhong Q, Li R, Li H, Ke Y, Lin J (2016) The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 25(9):2849–2857CrossRefPubMed

36.

Ward CFME, Benumo JL, Trousdale F (1980) A computer nomogram for blood loss replacement. Anesthesiology 53:126CrossRef

37.

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 9:13CrossRefPubMedPubMedCentral

Title: Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty
Authors: Ahmed Jawhar
Vera Stetzelberger
Karl Kollowa
Udo Obertacke
Publication date: 01-07-2019
Publisher: Springer Berlin Heidelberg
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 7/2019
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-018-5330-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty

Abstract

Purpose

Methods

Results

Conclusions

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Level of evidence

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