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Archives of Orthopaedic and Trauma Surgery

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01-06-2021 | Incision | Knee Arthroplasty

Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes

Authors: Filippo Migliorini, Nicola Maffulli, Paolo Aretini, Andromahi Trivellas, Markus Tingart, Jörg Eschweiler, Alice Baroncini

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 6/2021

Abstract

Introduction

The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data.

Material and methods

The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons.

Results

Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group.

Conclusion

For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

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

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(6 Suppl):2–4. https://doi.org/10.1016/j.arth.2010.04.033CrossRefPubMed

Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J (2017) Timing of tourniquet release in total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 96(17):e6786. https://doi.org/10.1097/MD.0000000000006786CrossRef

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-yCrossRefPubMed

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 Arthroplasty 30(1):31–37. https://doi.org/10.1016/j.arth.2014.07.034CrossRefPubMed

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(7):1121–1130. https://doi.org/10.1007/s00167-010-1342-7CrossRefPubMed

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(1):2309499016684323. https://doi.org/10.1177/2309499016684323CrossRef

Ozkunt O, Sariyilmaz K, Gemalmaz HC, Dikici F (2018) The effect of tourniquet usage on cement penetration in total knee arthroplasty: A prospective randomized study of 3 methods. Medicine (Baltimore) 97(4):e9668. https://doi.org/10.1097/MD.0000000000009668CrossRef

Dincel YM, Sari A, Cetin MU, Gunaydin B, Agca E, Dogan AH, Varol R (2020) The effect of tranexamic acid and tourniquet use on tibial cement penetration in Primary Total Knee arthroplasties. Arthroplast Today 6(3):422–426. https://doi.org/10.1016/j.artd.2020.04.010CrossRefPubMedPubMedCentral

10.

McCarthy Deering E, Hu SY, Abdulkarim A (2019) Does tourniquet use in TKA increase postoperative pain? a systematic review and meta-analysis. Clin Orthop Relat Res 477(3):547–558. https://doi.org/10.1097/CORR.0000000000000572CrossRefPubMed

11.

Tie K, Hu D, Qi Y, Wang H, Chen L (2016) Effects of tourniquet release on total knee arthroplasty. Orthopedics 39(4):e642-650. https://doi.org/10.3928/01477447-20160606-03CrossRefPubMed

12.

Wang C, Zhou C, Qu H, Yan S, Pan Z (2018) Comparison of tourniquet application only during cementation and long-duration tourniquet application in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 13(1):216. https://doi.org/10.1186/s13018-018-0927-6CrossRefPubMedPubMedCentral

13.

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(1):110–123. https://doi.org/10.1007/s00776-014-0664-6CrossRefPubMed

14.

Leurcharusmee P, Sawaddiruk P, Punjasawadwong Y, Chattipakorn N, Chattipakorn SC (2018) The possible pathophysiological outcomes and mechanisms of tourniquet-induced ischemia-reperfusion injury during total knee arthroplasty. Oxid Med Cell Longev 2018:8087598. https://doi.org/10.1155/2018/8087598CrossRefPubMedPubMedCentral

15.

Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, Ioannidis JP, Straus S, Thorlund K, Jansen JP, Mulrow C, Catala-Lopez F, Gotzsche PC, Dickersin K, Boutron I, Altman DG, Moher D (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162(11):777–784. https://doi.org/10.7326/M14-2385CrossRefPubMed

16.

Howick J CI, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H, Goddard O, Hodgkinson M (2011) The 2011 oxford levels of evidence. Oxford centre for evidence-based medicine

17.

Abdel-Salam KS AE (1995) Effects of tourniquet during total knee arthroplasty. A prospective randomized study. J Bone Joint Surg 77:250–253CrossRef

18.

Aglietti P, Baldini A, Vena LM, Abbate R, Fedi A, Falciani M (2000) Effect of tourniquet use on activation of coagulation in total knee arthropalsty. Clin Orthop Relat Res 371:169–177CrossRef

19.

Ajnin S, Fernandes R (2020) Reduced length of stay and faster recovery after total knee arthroplasty without the use of tourniquet. J Clin Orthop Trauma 11(1):129–132. https://doi.org/10.1016/j.jcot.2019.08.016CrossRefPubMed

20.

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/s00167-018-5196-8CrossRefPubMed

21.

Ayik O, Demirel M, Birisik F, Ersen A, Balci HI, Sahinkaya T, Batibay SG, Ozturk I (2020) The effects of tourniquet application in total knee arthroplasty on the recovery of thigh muscle strength and clinical outcomes. J Knee Surg. https://doi.org/10.1055/s-0040-1701454CrossRefPubMed

22.

Bakker SMK, Kosse NM, Crnic S, Scheffer GJ, Stienstra R (2019) Influence of a tourniquet on opioid consumption after local infiltration analgesia for total knee arthroplasty. Turk J Anaesthesiol Reanim 47(2):107–111. https://doi.org/10.5152/TJAR.2019.30906CrossRefPubMedPubMedCentral

23.

Barker T, Rogers VE, Brown KB, Henriksen VT, Rasmussen GL (2017) Tourniquet use during total knee arthroplasty does not modulate the neutrophil-to-lymphocyte ratio, pain, or activity. J Orthop Traumatol 18(3):283–287. https://doi.org/10.1007/s10195-016-0435-6CrossRefPubMed

24.

Barros M, Ribeiro EJC, Dias RG (2017) Blood level changes in total knee arthroplasty with and without a tourniquet. Rev Bras Ortop 52(6):725–730. https://doi.org/10.1016/j.rboe.2017.10.001CrossRefPubMedPubMedCentral

25.

Barwell J, Anderson G, Hassa A, Rawlins I (1997) The effects of early tourniquet release during total knee arthroplasty. J bone Joint Surg 79:265–268CrossRef

26.

Burg A, Dudkiewicz I, Heller S, Salai M, Velkes S (2009) The effect of using a tourniquet in total knee arthroplasty: a study of 77 patients. J Musculoskelet Res 12:137–142CrossRef

27.

Cao Q, He Z, Fan Y, Meng J, Yuan T, Zhao J, Bao N (2020) Effects of tourniquet application on enhanced recovery after surgery (ERAS) and ischemia-reperfusion post-total knee arthroplasty: Full- versus second half-course application. J Orthop Surg (Hong Kong) 28(1):2309499019896026. https://doi.org/10.1177/2309499019896026CrossRef

28.

Concina C, Crucil M, Fabbro S, Gherlinzoni F (2019) Do tourniquet and drainage influence fast track in total knee arthroplasty? Our results on 151 cases. Acta Biomed 90(1-S):123–129. https://doi.org/10.23750/abm.v90i1-S.8080

29.

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(1):69–77. https://doi.org/10.1007/s11999-015-4393-8CrossRefPubMed

30.

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(4):422–426. https://doi.org/10.3109/17453674.2014.931197CrossRefPubMedPubMedCentral

31.

Ejaz A, Laursen AC, Jakobsen T, Rasmussen S, Nielsen PT, Laursen MB (2015) Absence of a tourniquet does not affect fixation of cemented TKA: a randomized RSA study of 70 patients. J Arthroplasty 30(12):2128–2132. https://doi.org/10.1016/j.arth.2015.05.058CrossRefPubMed

32.

Fan Y, Jin J, Sun Z, Li W, Lin J, Weng X, Qiu G (2014) The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. Knee 21(6):1263–1268. https://doi.org/10.1016/j.knee.2014.08.002CrossRefPubMed

33.

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. Arch Orthop Trauma Surg 127(8):671–675. https://doi.org/10.1007/s00402-006-0244-0CrossRefPubMed

34.

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.19.00146CrossRefPubMed

35.

Guler O, Mahirogullari M, Isyar M, Piskin A, Yalcin S, Mutlu S, Sahin B (2016) Comparison of quadriceps muscle volume after unilateral total knee arthroplasty with and without tourniquet use. Knee Surg Sports Traumatol Arthrosc 24(8):2595–2605. https://doi.org/10.1007/s00167-015-3872-5CrossRefPubMed

36.

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(2):126–130. https://doi.org/10.1016/j.knee.2014.12.010CrossRefPubMed

37.

Harvey EJ, Leclerc J, Brooks CE, D.L. B, (1997) Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty. J Arthroplasty 12(3):291–296CrossRefPubMed

38.

Hasanain MS, Apostu D, Alrefaee A, Tarabichi S (2018) Comparing the effect of tourniquet vs tourniquet-less in simultaneous bilateral total knee arthroplasties. J Arthroplasty 33(7):2119–2124. https://doi.org/10.1016/j.arth.2018.02.013CrossRefPubMed

39.

Hassouna HZ, Butt U, Kamal B, Appado R, Qureshi A (2017) Tourniquet use in TKR: a potential predictor of postoperative pain scores in males and females. EC Orthop 7:188–194

40.

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(4):561–570. https://doi.org/10.1007/s00402-014-1948-1CrossRefPubMed

41.

Jawhar A, Hermanns S, Ponelies N, Obertacke U, Roehl H (2016) Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 24(10):3313–3321. https://doi.org/10.1007/s00167-015-3859-2CrossRefPubMed

42.

Jawhar A, Stetzelberger V, Kollowa K, Obertacke U (2019) Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 27(7):2071–2081. https://doi.org/10.1007/s00167-018-5330-7CrossRefPubMed

43.

Jawhar A, Skeirek D, Stetzelberger V, Kollowa K, Obertacke U (2019) No effect of tourniquet in primary total knee arthroplasty on muscle strength, functional outcome, patient satisfaction and health status: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-019-05646-5CrossRefPubMed

44.

Jorn LP, Lindstrand A, Toksvig-Larsen S (1999) Tourniquet release for hemostasis increases bleeding. A randomized study of 77 knee replacements. Acta Orthop Scand 70(3):265–267. https://doi.org/10.3109/17453679908997804CrossRefPubMed

45.

Kato N, Kazuhiro N, Shinichi Y (2002) Abnormal Echogenic Findings Detected by Transesophageal Echocardiography and Cardiorespiratory Impairment during Total Knee Arthroplasty with Tourniquet. Anesthesiology 97:1123–1128CrossRefPubMed

46.

Kim TK, Bamne AB, Sim JA, Park JH, Na YG (2019) Is lower tourniquet pressure during total knee arthroplasty effective? A prospective randomized controlled trial. BMC Musculoskelet Disord 20(1):275. https://doi.org/10.1186/s12891-019-2636-7CrossRefPubMedPubMedCentral

47.

Kirmani SJ, Middleton M, Fontalis A, Srivastava R (2018) A comparison of blood loss and the need for transfusion following primary total knee replacement with or without the use of a tourniquet. Int J Res Orthop 4(4):532–537CrossRef

48.

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(2):85–88. https://doi.org/10.1016/j.jcot.2015.01.095CrossRefPubMedPubMedCentral

49.

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(5):499–503. https://doi.org/10.3109/17453674.2012.727078CrossRefPubMedPubMedCentral

50.

Li B, Wen Y, Wu H, Qian Q, Lin X, Zhao H (2009) The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop 33(5):1263–1268. https://doi.org/10.1007/s00264-008-0647-3CrossRefPubMed

51.

Liu PL, Li DQ, Zhang YK, Lu QS, Ma L (2017) Influence of tourniquet on wound healing in total knee arthroplasty: a randomized and paired clinical trial. Int J Clin Exp Med 10(2):3653–3660

52.

Liu D, Graham D, Gillies K, Gillies RM (2014) Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. Knee Surg Relat Res 26(4):207–213. https://doi.org/10.5792/ksrr.2014.26.4.207CrossRefPubMedPubMedCentral

53.

Li Z, Liu D, Long G, Ke G, Xiao A, Tang P, Dong J (2017) Association of tourniquet utilization with blood loss, rehabilitation, and complications in Chinese obese patients undergoing total knee arthroplasty: A retrospective study. Medicine (Baltimore) 96(49):e9030. https://doi.org/10.1097/MD.0000000000009030CrossRef

54.

Liu PL, Li DQ, Zhang YK, Lu QS, Ma L, Bao XZ, Zhang M (2017) Effects of unilateral tourniquet used in patients undergoing simultaneous bilateral total knee arthroplasty. Orthop Surg 9(2):180–185. https://doi.org/10.1111/os.12329CrossRefPubMedPubMedCentral

55.

Urbano Manero EM, Miguelena Bobadilla JM (2012) Timing of tourniquet release in total knee arthroplasty doesn’t affect on transfusion needs. Rev Esp Anestesiol Reanim 59(10):556–561. https://doi.org/10.1016/j.redar.2012.07.020CrossRefPubMed

56.

Matziolis D, Perka C, Hube R, Matziolis G (2011) Influence of tourniquet ischemia on perioperative blood loss after total knee arthroplasty. Orthopade 40(2):178–182. https://doi.org/10.1007/s00132-010-1727-9CrossRefPubMed

57.

Mittal R, Ko V, Adie S, Naylor J, Dave J, Dave C, Harris IA, Hackett D, Ngo D, Dietsch S (2012) Tourniquet application only during cement fixation in total knee arthroplasty: a double-blind, randomized controlled trial. ANZ J Surg 82(6):428–433. https://doi.org/10.1111/j.1445-2197.2012.06083.xCrossRefPubMed

58.

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(2):396–401. https://doi.org/10.1016/j.knee.2013.10.008CrossRefPubMed

59.

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.2016.02.007CrossRefPubMed

60.

Mutlu S, Guler O, Mutlu H, Karaman O, Duymus TM, Parmaksizoglu AS (2015) Tourniquet use during total knee arthroplasty does not offer significant benefit: A retrospective cohort study. Int J Surg 18:123–127. https://doi.org/10.1016/j.ijsu.2015.04.054CrossRefPubMed

61.

Na YG, Bamne AB, Won HH, Kim TK (2017) After early release of tourniquet in total knee arthroplasty, should it be reinflated or kept deflated? A randomized trial. Knee Surg Sports Traumatol Arthrosc 25(9):2769–2777. https://doi.org/10.1007/s00167-015-3710-9CrossRefPubMed

62.

Paredes-Carnero X, Rosero-Ruiz GL, Centeno-Garcia JJ, Pombo-Taboada FJ (2015) Effect of removing the ischaemia tourniquet on the transfusion needs of the patient undergoing primary knee arthroplasty. Rev Esp Cir Ortop Traumatol 59(6):394–399. https://doi.org/10.1016/j.recot.2015.05.010CrossRefPubMed

63.

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(1):96–101. https://doi.org/10.1007/s00167-014-3341-6CrossRefPubMed

64.

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(4):335–342. https://doi.org/10.1055/s-0034-1388654CrossRefPubMed

65.

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.16.00750CrossRefPubMed

66.

Tai TW, Chang CW, Lai KA, Lin CJ, Yang CY (2012) Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am 94(24):2209–2215. https://doi.org/10.2106/JBJS.K.00813CrossRefPubMed

67.

Tarwala R, Dorr LD, Gilbert PK, Wan Z, Long WT (2014) Tourniquet use during cementation only during total knee arthroplasty: a randomized trial. Clin Orthop Relat Res 472(1):169–174. https://doi.org/10.1007/s11999-013-3124-2CrossRefPubMed

68.

Tetisma XM, Tamminga R, Snoeker BAM, Lucas C, Van der Hart CP, Felizer QGB (2015) Effect of tourniquet application on post-operative functional outcome following total knee arthroplasty: a prospective cohort study. Orthop Muscular Syst 4(3):1–7

69.

Tetro AM (2001) The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Canadian Med Ass 44(2):33–38

70.

Touzopoulos P, Ververidis A, Mpogiatzis C, Chatzigiannakis A, Drosos GI (2019) The use of tourniquet may influence the cement mantle thickness under the tibial implant during total knee arthroplasty. Eur J Orthop Surg Traumatol 29(4):869–875. https://doi.org/10.1007/s00590-019-02369-8CrossRefPubMed

71.

Unver B, Karatosun V, Tuncali B (2013) Effects of tourniquet pressure on rehabilitation outcomes in patients undergoing total knee arthroplasty. Orthop Nurs 32(4):217–222. https://doi.org/10.1097/NOR.0b013e31829aef2aCrossRefPubMed

72.

Vaishya R, Agarwal AK, Vijay V, Tiwari MK (2018) Short term outcomes of long duration versus short duration tourniquet in primary total knee arthroplasty: A randomized controlled trial. J Clin Orthop Trauma 9(1):46–50. https://doi.org/10.1016/j.jcot.2017.11.016CrossRefPubMed

73.

Vandenbussche E, Duranthon LD, Couturier M, Pidhorz L, Augereau B (2002) The effect of tourniquet use in total knee arthroplasty. Int Orthop 26(5):306–309. https://doi.org/10.1007/s00264-002-0360-6CrossRefPubMedPubMedCentral

74.

Wakankar HM, Nicholl JE, Koka R, Darcy JC (1999) The tourniquet in total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br 81(1):30–33. https://doi.org/10.1302/0301-620x.81b1.8971CrossRefPubMed

75.

Wang K, Ni S, Li Z, Zhong Q, Li R, Li H, Ke Y, Lin J (2017) The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 25(9):2849–2857. https://doi.org/10.1007/s00167-015-3964-2CrossRefPubMed

76.

Watters T, Levy D, Kim R, Miner T, Dennis D (2016) Arthroplasty does not benefit perioperative blood loss or transfusion requirement with the routine use of tranexamic acid. Reconstr Rev 6(3):43–47

77.

Wauke K, Nagashima M, Kato N, Ogawa R, Yoshino S (2002) Comparative study between thromboembolism and total knee arthroplasty with or without tourniquet in rheumatoid arthritis patients. Arch Orthop Trauma Surg 122(8):442–446. https://doi.org/10.1007/s00402-002-0404-9CrossRefPubMed

78.

Widman J, Isacson J (1999) Surgical hemostasis after tourniquet release does not reduce blood loss in knee replacement. A prospective randomized study of 81 patients. Acta Orthop Scand 70(3):268–270. https://doi.org/10.3109/17453679908997805CrossRefPubMed

79.

Yavarikia A, Amjad GG, Davoudpour K (2010) The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty. Pakistan J Bio Sci 13(5):249–252CrossRef

80.

Zan P, Mol MO, Yao JJ, Fan L, Yang D, Liu K, Li G (2017) Release of the tourniquet immediately after the implantation of the components reduces the incidence of deep vein thrombosis after primary total knee arthroplasty. Bone Joint Res 6(9):535–541. https://doi.org/10.1302/2046-3758.69.BJR-2017-0149.R2CrossRefPubMedPubMedCentral

81.

Zhang Y, Li D, Liu P, Wang X, Li M (2017) Effects of different methods of using pneumatic tourniquet in patients undergoing total knee arthroplasty: a randomized control trial. Ir J Med Sci 186(4):953–959. https://doi.org/10.1007/s11845-017-1585-0CrossRefPubMed

82.

Zhou K, Ling T, Wang H, Zhou Z, Shen B, Yang J, Kang P, Pei F (2017) Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. J Orthop Surg Res 12(1):172. https://doi.org/10.1186/s13018-017-0683-zCrossRefPubMedPubMedCentral

83.

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/s13018-019-1422-4CrossRefPubMedPubMedCentral

84.

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 Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-019-05617-wCrossRefPubMedPubMedCentral

85.

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(6):973–986. https://doi.org/10.1007/s00590-013-1278-yCrossRefPubMed

86.

Papalia R, Zampogna B, Franceschi F, Torre G, Maffulli N, Denaro V (2014) Tourniquet in knee surgery. Br Med Bull 11(1):63–76. https://doi.org/10.1093/bmb/ldu012CrossRefPubMed

87.

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(7):445–451. https://doi.org/10.3928/01477447-20150701-06CrossRefPubMed

88.

American Society of Anesthesiologists Task Force on Perioperative Blood T, Adjuvant T (2006) Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 105(1):198–208. https://doi.org/10.1097/00000542-200607000-00030CrossRef

89.

Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G (2009) Recommendations for the transfusion of red blood cells. Blood Transfus 7(1):49–64. https://doi.org/10.2450/2008.0020-08CrossRefPubMedPubMedCentral

90.

Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G, Italian Society of Transfusion M, Immunohaematology Working P (2011) Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period. Blood Transfus 9(3):320–335. https://doi.org/10.2450/2011.0076-10CrossRefPubMed

91.

Rosenstein AD, Michelov YA, Thompson S, Kaye AD (2016) Benefits of limited use of a tourniquet combined with intravenous tranexamic acid during total knee arthroplasty. Ochsner J 16(4):443–449PubMedPubMedCentral

92.

Patel NK, Johns W, Vedi V, Langstaff RJ, Golladay GJ (2020) Tourniquet and tranexamic acid use in total knee arthroplasty. Arthroplast Today 6(2):246–250. https://doi.org/10.1016/j.artd.2020.02.007CrossRefPubMedPubMedCentral

Title: Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes
Authors: Filippo Migliorini
Nicola Maffulli
Paolo Aretini
Andromahi Trivellas
Markus Tingart
Jörg Eschweiler
Alice Baroncini
Publication date: 01-06-2021
Publisher: Springer Berlin Heidelberg
Keyword: Incision
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 6/2021
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-020-03725-8

At a glance: The STEP trials

Springer Medicine

Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes

Abstract

Introduction

Material and methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Material and methods

Results

Conclusion

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