Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty
Department of Orthopaedic Surgery, Mie University Faculty of Medicine, 2-174 Edobashi, Tsu city, Mie 514-8507, Japan. Archives of Orthopaedic and Trauma Surgery
(Impact Factor: 1.6).
11/2007; 127(8):671-5. DOI: 10.1007/s00402-006-0244-0
There is a great deal of controversy about the effect of tourniquets on development of deep vein thrombosis (DVT) after total knee arthroplasty (TKA).
We investigated the incidence of postoperative DVT after TKA with or without the use of a tourniquet. The patients were 48 consecutive patients undergoing primary ipsilateral cemented TKA for osteoarthritis. Group A (21 patients) underwent the operation without a tourniquet, and Group B (27 patients) underwent the operation with a tourniquet. Ultrasonography to assess DVT was performed before and after the operation.
Group B had less intraoperative and total blood loss than Group A. Postoperative DVT was detected in 81.3% of all cases, and symptomatic pulmonary embolism occurred in 1.7%. Most of DVT was found in the calf vein. There was no significant difference in the incidence of postoperative DVT between the two groups.
We conclude that the use of a tourniquet is beneficial, because it decreases perioperative blood loss and does not increase the risk of DVT. The incidence of DVT after TKA is considerably high with or without use of a tourniquet. Therefore, prevention and early detection of DVT are important for prevention of fatal pulmonary thromboembolism.
Available from: Soren Overgaard
- "The rationale for tourniquet use in TKA is primarily the optimization of intra-operative visibility and reduced blood loss
[9,12,14,15]. However, such benefits must be weighed against the potential complications which include; increased risk of direct vascular injury
[13,16], nerve palsy
[17-19], deep-vein thrombosis
[7,8,13,20] and subsequent pulmonary embolism
[7,21,22]. Additionally, acute pulmonary edema and cardiac arrest immediately following tourniquet release have been reported
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ABSTRACT: Surgical treatment of osteoarthritis with total knee arthroplasty (TKA) usually takes place in a complete bloodless field using a tourniquet. However, doing the surgery without a tourniquet may reduce muscle damage, post-surgery pain and led to improved functional rehabilitation and mobilization.Methods/design: A prospective, blinded, parallel-group, controlled superiority trial, with balanced randomization [1:1]. Patients aged 50 or older eligible for primary TKA for osteoarthritis will be consecutively recruited from Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Denmark. A total of 80 patients will be randomly allocated to TKA with or without tourniquet application providing 40 patients for each of the two treatment arms. The tourniquet assisted TKA group will have an automatic, micro-processor-based pneumatic tourniquet inflated around the thigh during surgery. The non-tourniquet assisted TKA group will have surgery performed without application of a tourniquet. The primary aim is to compare tourniquet assisted to non-tourniquet assisted TKA on patient-reported physical function (KOOS-ADL). The secondary aim is to compare post-surgery pain, function in sports and recreation, quality of life, and performance-based physical function. The explorative outcomes include; use of pain medication, single-fiber muscle damage, and changes in mechanical muscle function. The primary endpoint will be at 3-months following surgical treatment, and the time-point for analysis of the primary outcome. However, follow-up will continue up to 1 year, and provide medium-term results. The treatment effect (difference in KOOS-ADL) will be analyzed using a random effects regression model, crude and adjusted results will be reported, if needed. Analyses will be based on the intention-to-treat (ITT). Subsequent per-protocol analysis may be necessary in the event of a substantial number of patients (> 15%) being lost during follow-up. The number needed to treat (NNT) for a positive effect of treatment (>10 points on KOOS-ADL) will be reported.
This is the first randomized clinical trial comparing the efficacy of tourniquet assisted TKA on patient-reported physical function supported by a range of performance-based secondary outcome measures. As such it will provide high quality evidence that may help determine whether tourniquet should be used in future TKA procedures in patients with osteoarthritis of the knee.Trial registration: ClinicalTrials NCT01891266.
Available from: Wei Zhang
- "Our study indicated that using a tourniquet in TKA might increase the morbidity rate. The reasons are as follows: The formation of thrombi is associated with the triad of venous stasis, endothelial injury, and hypercoagulability, which is present in patients being managed with TKA
. A tourniquet can cause venous stasis, endothelial damage via direct trauma, and possible damage to calcified blood vessels. "
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ABSTRACT: The purpose of this research is to evaluate the effects of a tourniquet in total knee arthroplasty (TKA).
The study was done by randomized controlled trials (RCTs) on the effects of a tourniquet in TKA. All related articles which were published up to June 2013 from Medline, Embase, and Cochrane Central Register of Controlled Trails were identified. The methodological quality of the included studies was assessed by the Physiotherapy Evidence Database (PEDro) scale. The meta-analysis was performed using Cochrane RevMan software version 5.1.
Thirteen RCTs that involved a total of 689 patients with 689 knees were included in the meta-analysis, which were divided into two groups. The tourniquet group included 351 knees and the non-tourniquet group included 338 knees. The meta-analysis showed that using a tourniquet in TKA could reduce intraoperative blood loss (weighted mean difference (WMD), -198.21; 95% confidence interval (CI), -279.82 to -116.60; P < 0.01) but did not decrease the calculated blood loss (P = 0.80), which indicates the actual blood loss. Although TKA with a tourniquet could save the operation time for 4.57 min compared to TKA without a tourniquet (WMD, -4.57; 95% CI, -7.59 to -1.56; P < 0.01), it had no clinical significance. Meanwhile, the use of tourniquet could not reduce the possibility of blood transfusion (P > 0.05). Postoperative knee range of motion (ROM) in tourniquet group was 10.41[degree sign] less than that in the non-tourniquet group in early stage (<=10 days after surgery) (WMD, -10.41; 95% CI, -16.41 to -4.41; P < 0.01). Moreover, the use of a tourniquet increased the risk of either thrombotic events (risk ratio (RR), 5.00; 95% CI, 1.31 to 19.10; P = 0.02) or non-thrombotic complications (RR, 2.03; 95% CI, 1.12 to 3.67; P = 0.02).
TKA without a tourniquet was superior to TKA with a tourniquet in thromboembolic events and the other related complications. There were no significant differences between the two groups in the actual blood loss. TKA with a tourniquet might hinder patients' early postoperative rehabilitation exercises.
Available from: sciencedirect.com
- "Among the more common or significant complications were compartment syndrome, deep vein thrombosis, skin injuries, and neurological complications  . However, no increases in DVT rates were observed when tourniquets were used in the operative setting . The use of tourniquets in total knee arthroplasty cases was associated with local thrombogenic and fibrinolytic activity, but without systemic changes in thrombosis or fibrinolysis. "
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Haemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early.
The study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion.
190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1 h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died.
Tourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.
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