More pain and slower functional recovery when a tourniquet is used during total knee arthroplasty

Abstract

Purpose Although a tourniquet can effectively control intraoperative blood loss and offer clear surgical field in total knee arthroplasty (TKA), its optimal usage has been controversial. The aim of this research was to perform a systematic review and meta‐analysis to compare and explore the best application of a tourniquet in TKA. Methods MEDLINE, PubMed, EMBASE, the Cochrane Library, Wanfang database, and Web of Science were searched for randomized controlled trials (RCTs) comparing the four different strategies of tourniquet application in TKA. In Group I, a tourniquet was not used and was called the non‐tourniquet (NT) group. In Group II, a tourniquet was only used during the cementation of implants and was called the specific duration tourniquet (SDT) group. In Group III, the tourniquet was only released before wound closure to control the bleeding sources and was called the majority duration tourniquet (MDT) group. In Group IV, a tourniquet was used throughout the procedure, from skin incision to wound closure and was called the whole duration tourniquet (WDT) group. Results Forty‐six RCTs were included in this systematic review and meta‐analysis. In a comparison between the NT and WDT groups (25 RCTs), intraoperative blood loss (IBL) (P = 0.0001) and range of motion (ROM) (P = 0.0001) were significantly increased in the NT group, while the visual analog score (VAS) (P = 0.0001), rate of deep vein thrombosis (DVT) (P = 0.01), and all complications (AC) (P = 0.0001) were significantly decreased in the NT group. In a comparison between the SDT and WDT groups (10 RCTs), IBL (P = 0.0001), TBL (P = 0.009), and ROM (P = 0.0001) were significantly increased in the SDT group, while thigh pain (P = 0.04) and the rate of DVT (P = 0.03) were significantly decreased in the SDT group. There were no significant differences between the MDT and WDT groups (12 RCTs) except for the rate of all complications (P = 0.01). Conclusion Despite the decrease in IBL with a tourniquet, no difference was found in TBL. In conclusion, not using a tourniquet or only using it during the cementation of implants was preferable based on the faster functional recovery, lower rate of DVTs and complications compared with using a tourniquet throughout the TKA procedure. Level of evidence I.

Tourniquet use in routine primary total knee arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a real-world study

“…Besides this, tourniquet use in TKA may be related to increased postoperative knee pain and swelling. A systematic review and meta-analysis of 46 RCTs demonstrated that tourniquet use in TKA caused more pain [29]. Moreover, two studies [30,31] reported that tourniquet application in TKA was associated with a higher opioid consumption, which equates to increased pain related to tourniquet use.…”

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

“…Similar results were reported by Zhang et al [3] in 2017 from eight studies comparing incision-to-suture versus a full-time tourniquet regime. Likewise, in 2019, Liu et al [84] analysed operating times across several tourniquet protocols, evidencing significantly longer surgeries in the absence group compared to the fulltime tourniquet group (P = 0.005). On the other hand, Wang et al [12] found no difference in surgical duration between shorter tourniquet use during cementation only and longer tourniquet use across 338 procedures; however, their findings were compromised by a high level of heterogeneity across the data.…”

The effect of limited versus no tourniquet use on rapid recovery in total knee replacement--a randomized controlled trial

“…It has been suggested that long-term use of tourniquet can reduce intraoperative and intraoperative total blood loss, while short-term use of tourniquet can reduce postoperative and postoperative hidden blood loss without increasing the rate of allogeneic blood transfusion [23]. Interestingly, some studies found that 48 h after total knee arthroplasty, the strength of knee extension was not superior in the group without tourniquet, but tourniquet caused lower limb pain [24,25]; others suggested that the use of tourniquet had no signi cant correlation with postoperative rehabilitation [26]. In summary, studies on tourniquet use or not have been reported, but there is little literature comparing postoperative rehabilitation with limited tourniquet use versus no tourniquet use.…”