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TKA without tourniquet application improves the speed of functional recovery
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October 2014
TKA without tourniquet application improves the speed of functional recovery
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Faster recovery without the use of a tourniquet in total knee arthroplasty
Acta Orthop. 2014 Aug;85(4):422-6. doi: 10.3109/17453674.2014.931197. Epub 2014 Jun 23.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
70 patients with stage 3-5 gonarthrosis were randomized to undergo total knee arthroplasty (TKA) with or without the application of a tourniquet. The purpose of this trial was to determine whether TKA should be performed with or without the use of a tourniquet, based on functional and clinical outcomes at one year postoperatively. Results revealed that TKA without the use of a tourniquet significantly improved KOOS functional outcomes and knee range of motion up to 8 weeks after surgery, but resulted in greater intraoperative bleeding compared to TKA using a tourniquet. However, neither group required transfusion following TKA.
Publication Funding Details
+
Funding:
Not Reported
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Randomization
2/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Tourniquets are frequently used to reduce intraoperative bleeding during total knee arthroplasty (TKA). While they may offer the potential to improve blood loss, visual field, surgical time, and quality of cementation, they are also associated with postoperative disadvantages including heightened pain, reduced muscle strength, and limited knee range of motion. Thus, this study was needed to investigate whether the advantages of tourniquet use during TKA outweigh the potential for adverse effects. The authors hypothesized non-tourniquet patients would achieve improved functional outcomes, increased knee range of motion, reduced postoperative pain, and lowered analgesic consumption.
What was the principal research question?
How does total knee arthroplasty with and without the use of a tourniquet compare with respect to functional and clinical outcomes over the first postoperative year?
Study Characteristics
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Population:
70 patients 50-85 years of age with stage 3-5 gonarthrosis for which they were scheduled undergo elective unilateral total knee arthroplasty were included in this study. All surgeries were standardized with respect to preoperative tranexamic acid administration, spinal anesthesia, postoperative pain treatment, and rehabilitation regimen.
Intervention:
Non-tourniquet group: A tourniquet was applied to the thigh but not inflated during primary, elective unilateral total knee arthroplasty, serving as a safety device in case of uncontrollable bleeding (n = 35, 31 analyzed; mean age: 68 +/- 7.8, M=17/F=14).
Comparison:
Tourniquet group: A tourniquet was applied to the thigh (elevation for 2 minutes) and inflated to 250 mmHg during primary, elective unilateral total knee arthroplasty as per standard procedure (n = 35, 33 analyzed; mean age: 68 +/- 8.4, M=18/F=15).
Outcomes:
The primary outcomes of interest included functional and clinical outcomes, evaluated using the knee injury and osteoarthritis outcome score (KOOS) and knee range of motion (ROM). Intraoperative blood loss, surgical time and visibility, postoperative visual analog scale (VAS) pain, analgesic consumption, and transfusion requirements acted as secondary outcomes of interest.
Methods:
RCT: Prospective, Single-centered
Time:
Follow-up occurred day 2, 8 weeks, 6 months, and 12 months postoperative. Secondary outcomes were measured at rest preoperatively, and 2, 4, 6, 8, and 10 hours after surgery.
What were the important findings?
- The tourniquet and non-tourniquet groups both improved in all KOOS sub-scales (pain, symptoms, function in daily living, function in sport/rec, knee related quality of life) from baseline to 8 weeks, with significant improvement in the non-tourniquet group compared to the tourniquet group at day 2 postoperative (p<0.05).
- Knee range of motion was significantly superior in the non-tourniquet group compared to the tourniquet group day 2 postoperative (48 (SD 9.5, 95% CI: 44-51) degrees vs. 36 (SD 7.9, 95% CI: 33-39) degrees; p < 0.001) and 8 weeks after surgery (100 (SD 7.2, 95% CI: 97-102) degrees vs. 93 (SD 8.2, 95% CI: 90-6) degrees; p = 0.002). This difference was no longer detectable at the 6 or 12 month follow-up (both p>0.05).
- In the non-tourniquet group: mean VAS pain was significantly lower day 2 postoperative (4.6 (SD 1.4, 95% CI: 4.1-5.1) vs. 5.5 (SD 1.6, 95% CI: 5-6.1); p<0.02), analgesic consumption was lower, intraoperative bleeding was greater (280 (SD 52) mL vs. 140 (SD 32.7) mL) and surgical time/visibility was similar compared to the tourniquet group.
- No patients required transfusions.1 patient in the non-tourniquet group and 2 patients in the tourniquet group experienced deep vein thrombosis.
What should I remember most?
Total knee arthroplasty (TKA) without the use of a tourniquet improved KOOS functional outcomes and knee range of motion up to 8 weeks after surgery, but resulted in greater intraoperative bleeding compared to tourniquet use. However, no patient in either group required transfusion.
How will this affect the care of my patients?
Other than increased intraoperative bleeding, which did not lead to an increased need for transfusion, the absence of a tourniquet in total knee arthroplasty does not appear to result in any additional complications. In fact, the aforementioned findings found the absence of a tourniquet resulted in superior functional outcome, improved knee range of motion, as well as reduced pain and analgesia consumption compared to TKA with a tourniquet. Additional trials are required to confirm these results.
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