A tourniquet is often used in total knee arthroplasty resulting in improved visualization of structures, reduced intraoperative bleeding and better cementation. The risks include deep vein thrombosis and pulmonary embolism. To quantify the case for or against tourniquet use, we carried out a systematic review and meta-analysis of selected randomized controlled trials. Ten studies were included in the meta-analysis. Of the 8 outcomes analyzed (surgery duration; total, intraoperative, and postoperative blood losses; deep vein thrombosis; pulmonary embolism; and minor/major complications), the total and intraoperative blood losses were less using a tourniquet. Minor complications were more common in the tourniquet group. The remaining outcomes showed no difference between the groups. Using a tourniquet may be beneficial, but long-term studies of outcome are needed.

A comparison of outcomes with and without a tourniquet in total knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials

Proponents of tourniquets postulate that they optimise intra-operative visibility and reduce blood loss. This study compared the outcomes of tourniquet assisted to non-tourniquet assisted total knee replacement (TKR). A systematic review was undertaken of the electronic databases Medline, CINAHL, AMED and EMBASE, in addition to a review of unpublished material and a hand search of pertinent orthopaedic journals. The evidence-base was critically appraised using a tool from the Cochrane Bone, Joint and Muscle Trauma Group. Fifteen studies were identified evaluating 16 outcome measures and parameters of 1040 TKRs in 991 patients. There was a significantly greater intra-operative blood loss in non-tourniquet compared to tourniquet assisted surgery (p=0.004). There was no significant difference between the groups for total blood loss or transfusion rate (p=0.22; p=0.48). There was a trend for greater complications in tourniquet compared to non-tourniquet patients. There was no difference between the groups for any other outcome measure assessed. In conclusion, this systematic review has found that there is no advantage to using a tourniquet in knee replacement surgery for reduction of transfusion requirements.

Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review

The objective of this study was to examine the characteristics of hidden blood loss and assess the effects of using a tourniquet on postoperative hidden loss in patients undergoing primary total knee arthroplasty. Eighty patients were randomised into two groups: one group underwent operation with a tourniquet and one without. Operating time, perioperative blood loss, hidden blood loss, free haemoglobin, swelling, ecchymosis, straight leg raising action and knee flexion were measured. There were significant differences in the hidden blood loss, free haemoglobin, postoperative swelling, extent of ecchymosis, straight leg raising and postoperative knee flexion in the early period after operation between the two groups. Our results indicate that knee arthroplasty operations with a tourniquet might promote postoperative hidden blood loss and hinder patients’ in early postoperative rehabilitation exercises.

/pdf/the-effect-of-tourniquet-use-on-hidden-blood-loss-in-total-fidid0gip5.pdf

The effect of tourniquet use on hidden blood loss in total knee arthroplasty

We conducted a prospective, randomised study on primary total knee replacements to evaluate the effects of tourniquet use on total calculated blood loss using Gross formula, post-operative measured blood loss, operating time, need for blood transfusion, post-operative pain, analgesia requirement and knee flexion. Forty patients were operated on with the use of an arterial tourniquet with pressure of 350 mmHg (group A), and 40 patients without the use of a tourniquet (group B). Total calculated blood loss was significantly increased (P=0.0165) without the use of a tourniquet. There was no significant difference in measured blood loss or operating time. The median units of blood given were similar in both groups. In spite of autologous transfusions 14% of patients received additional homologous transfusions. At 6 h post-operatively pain was significantly less (P=0.0458) in group B but was similar at 24 and 48 h. There was no significant difference in analgesia requirement. The mean change in total flexion in group B was significantly better (P<0.001) at 5 days than in group A, but knee flexion was similar at 10 days and 3 months. Knee arthroplasty operations without the use of a tourniquet cause a greater blood loss but have only small benefits in the early post-operative period.

The effect of tourniquet use in total knee arthroplasty

Insertion of a metallic implant into the femur changes bone loading conditions and results in remodeling of femoral bone. To quantify changes in bone mass after uncemented total hip arthroplasty (THA), we monitored femoral bone with dual-energy X-ray absorptiometry (DXA). The periprosthetic bone mineral density (BMD) was measured with Lunar DPX densitometry in seven Gruen zones and the total periprosthetic area at scheduled time intervals in 22 patients during a 3-year follow-up. BMD decreased significantly almost in all Gruen zones during the first 3 months, ranging from 3.4% to 14.4% (p < 0.05 top < 0.001). At the end of the first year, the most remarkable decrease in BMD was found in the calcar (zone 7; -22.9%). During the second postoperative year, a slight restoration of periprosthetic bone mass was recorded. During the third year, no significant changes in BMD were found. The preoperative BMD was the only factor that was significantly related to the periprosthetic bone loss. Clearly, the early periprosthetic bone loss noticed during the 3 months after THA is caused by mainly limited weight bearing to the operated hip and stress shielding. We suggest that the restoration of bone mass is a sign of successful osteointegration between bone and metallic implant. DXA is a suitable tool to follow the bone response to prosthetization and will increase our knowledge on the behavior of bone after THA.

https://asbmr.onlinelibrary.wiley.com/doi/pdf/10.1359/jbmr.2001.16.6.1056

Monitoring of periprosthetic BMD after uncemented total hip arthroplasty with dual-energy X-ray absorptiometry--a 3-year follow-up study.

Tourniquet time and its relationship to blood loss and deep vein thrombosis were studied in 80 cases of unilateral total knee arthroplasty. These data were part of a prospective multicenter double-blind study on thromboprophylaxis for knee surgery. This study reports on the cases done at one institution in which the tourniquet was used in three different ways: group 1, no tourniquet use; group 2, limited tourniquet use for cementing time only; group 3, tourniquet use throughout the whole case. Blood loss was significantly related to tourniquet time (P = .0001). The incidence of deep vein thrombosis was not related to the tourniquet group (P = .9).

Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty.

Bone mineral density changes surrounding a porous-coated proximal modular sleeved hip prosthesis were determined as a function of time over a 24-month period. The periprosthetic bone regions were defined by the 7 Gruen zones. Measurements were obtained with a dual-energy x-ray densitometer using a dedicated software program. Inclusion criteria required that the patients had primary implants, were asymptomatic with Harris hip scores of ≥95 for the duration of the study, and showed no radiographic evidence of loosening. The protocol specified that bone measurements be obtained within 1 week after surgery as a baseline reference and at 3, 6, 9, 12, 18, and 24 months thereafter. A total of 111 consecutive patients were enrolled in this ongoing prospective study, of whom 52 had 4 or more measurements after the initial baseline determination for statistical analysis. At 3 months, all zones showed a significant decrease in bone mineral density relative to the baseline measurements, and their mean loss ranged from 6.5% to 11.2%. By 24 months, mineral losses relative to baseline varied from 0 to 11% for Gruen zones 1 to 6. Relative to the 3-month levels, there was no significant change in zones 1, 4, and 6; a significant improvement in zones 3 and 5; and a small but significant loss in zone 2 at 24 months. Gruen zone 7, the medial femoral neck cortex, differed in that it was the site of greatest bone mineral loss, attaining a mean of 20.2% at 24 months. It was found that the amount of periprosthetic mineral loss at 12 months was independent of the initial baseline reference bone mineral levels. Results of this study show the normal temporal bone mineral changes surrounding a proximally modular porous-coated femoral implant. The pattern of change demonstrated may be peculiar to the prosthesis used in this study because it might differ in implants of different design and material composition.

Temporal changes of periprosthetic bone density in patients with a modular noncemented femoral prosthesis.

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Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty.

Temporal changes of periprosthetic bone density in patients with a modular noncemented femoral prosthesis.