Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

Abstract

Background Tourniquet use during total knee arthroplasty (TKA) improves visibility and reduces intraoperative blood loss. However, tourniquet use may also have a negative impact on early recovery of muscle strength and lower extremity function after TKA. Questions/purposes The purpose of this study was (1) to determine whether tourniquet use affects recovery of quadriceps strength (primary outcome) during the first 3 postoperative months; and (2) to examine the effects of tourniquet application on secondary outcomes: voluntary quadriceps activation, hamstring strength, unilateral limb balance as well as the effect on operative time and blood loss.Methods Twenty-eight patients (mean age 62 ± 6 years; 16 men) undergoing same-day bilateral TKA (56 lower extremities) were enrolled in a prospective, randomized study. Subjects were randomized to receive a tourniquetassisted knee arthroplasty on one lower extremity while the contralateral limb underwent knee arthroplasty without extended tourniquet use. In the former group, the tourniquet was inflated just before the incision was made and released after cementation; in the latter group, a tourniquet was not used (10 of 28 [36%]) or inflated only during component cementation (18 of 28 [64%]). The choice of no tourniquet or use just during cementation was based on surgeon choice, because some surgeons felt a tourniquet during cementation was necessary to achieve a dry surgical field to maximize cement fixation. A median parapatellar approach and the One or more of the authors (DAD, CCY, TMM, RHK) has received funding from Porter Adventist Hospital, during the study period, in the amount of USD 10,000 to USD 100,000. One of the authors (DAD) has or may receive payments or benefits from DePuy (Warsaw, IN, USA) in the amount of USD more than USD 1,000,001 not related to this work. One of the authors certifies that he (RHK) has or may receive payments or benefits from Stryker (Kalamazoo, MI, USA) and Innomed (Savannah, GA, USA) in the amount of USD 100,001 to USD 1,000,001 not related to this work. One of the authors (TMM) has or may receive payments or benefits from Zimmer (Warsaw, IN, USA) in the amount of less than USD 10,000 not related to this work. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.The surgeries for this study were performed at Porter Adventist Hospital, Denver, CO, USA, and the postoperative patient te...

Tourniquet Application During Total Knee Arthroplasty Does Not Benefit Perioperative Blood Loss or Transfusion Requirement with the Routine Use of Tranexamic Acid

“…In a prospective randomized study of 28 patients undergoing same-day bilateral TKA where tourniquet was used throughout the procedure on one limb and not on the contralateral, Dennis et al found lower post-operative quadriceps strength on the limb with the tourniquet that persisted at 3 months after surgery [6]. A recent study by Huang et al, comparing 3 different tourniquet application strategies using a "mini-midvastus" approach, found that serum inflammatory and muscle injury markers were lowest in the group where tourniquet was used only for cementation and not for the entire procedure [18].…”

“…However, tourniquet usage may be a risk factor for postoperative thromboembolism [2,3], and other wound complications related to tissue hypoxia and reperfusion injury [4,5]. In addition, a recent study found that tourniquet usage may result in diminished quadriceps function during the first 3 months after surgery [6]. Two recent meta-analyses of the available randomized controlled trials (RCTs) on tourniquet usage both concluded that the available evidence supports the assertion that TKA with a tourniquet results in a significant decrease in intraoperative blood loss and transfusion rate, albeit with a slightly higher rate of minor wound complications [7,8].…”

Comparing the Effects of Two Tourniquet Times on Pain and Knee Range of Motion after Internal Plate Fixation of Tibia Fractures

“…It is believed that tourniquet use reduces ROM of joints through inflicting microscopic injuries to muscles, affecting cellular viability, and increasing postoperative pain and edema [16]. Dennis et al [35] also assessed the effects of tourniquet use on the function of lower extremities after knee arthroplasty and found that quadriceps strength in their no-tourniquet group was significantly higher than the tourniquet group. They observed this difference even three months after the surgery [36].…”

A comparison of blood loss and the need for transfusion following primary total knee replacement with or without the use of a tourniquet

“…This is presumed to be due to the lack of ischaemic injury to the limb as well as the crush injury to the musculature. [19][20][21] There is also recent evidence that when a tourniquet is not used the quadriceps musculature maintains a greater degree of strength, and the knee has a better range of movement. [20][21][22] These factors can all improve patient recovery.…”

“…[19][20][21] There is also recent evidence that when a tourniquet is not used the quadriceps musculature maintains a greater degree of strength, and the knee has a better range of movement. [20][21][22] These factors can all improve patient recovery. 22,23 The above findings and modern surgical and anaesthetic techniques have resulted in a trend to reduce the tourniquet time or even perform the surgery without a tourniquet.…”