Timing of tourniquet release in total knee arthroplasty

Abstract

Background:For total knee arthroplasty (TKA), the tourniquet is routinely employed for better visualization, less blood loss, and easier cementation. However, the time to release tourniquet remains controversial. Therefore, we performed current meta-analysis to assess whether releasing tourniquet before wound closure is more effective in reducing blood loss than releasing tourniquet after wound closure in TKA without an increased risk of complications.Methods:To conduct this meta-analysis, we searched Medline, Embase, Web of science, and the Cochrane library up to November 2016, for randomized controlled trials comparing tourniquet releasing before and after wound closure in TKA. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Methodological quality of the trials was assessed using the Cochrane risk assessment scale. The data of the included studies were analyzed using Stata 12.0.Results:Sixteen trials involving 1010 patients were identified in current meta-analysis. Our meta-analysis demonstrated that there were no significant differences in the 2 groups in terms of calculated blood loss (weighted mean difference [WMD] = 160.65, 95% confidence interval [CI]: −0.2 to 321.49, P = .05), postoperative blood loss (WMD = −45.41, 95% CI: −120.11 to 29.29, P = .233),postoperative hemoglobin decline (WMD = 0.16, 95% CI: −2.5 to 2.82, P = .905), transfusion volume (WMD = 79.19, 95% CI: −5.05 to 163.44, P = .065),transfusion rates (relative risk [RR] = 1.19, 95% CI: 0.95–1.50, P = .134), major complications (RR = 0.51, 95% CI: 0.15–1.73, P = .278), and deep vein thrombosis (RR = 0.44, 95% CI: 0.14–1.37, P = .157).Compared with the group of releasing tourniquet after wound closure, the group of releasing tourniquet before wound closure had a higher volume of total blood loss (WMD = 130.96, 95% CI: 58.83–203.09, P = .000) and a longer operation time (WMD = 6.56, 95% CI: 3.12–10.01, P = .000). However, releasing tourniquet before wound closure could reduce minor complications (RR = 0.53, 95% CI: 0.34–0.82, P = .004).Conclusions:On the basis of current meta-analysis, the method of releasing tourniquet before wound closure could increase total blood loss and operation time; nevertheless, the risk of complications decreased. Thus, if patients are in severe anemia condition, the tourniquet perhaps should be released after wound closure to decrease blood loss. In contrary, releasing tourniquet before wound closure to decrease the risk of complications would be a better choice.

Tourniquet Use in Total Knee Arthroplasty

“…Nonetheless there was no significant difference in transfusion requirements between groups. Huang et al 28 conducted a systematic review and meta-analysis on early versus later tourniquet release and found significantly higher intraopera-tive blood loss in the early release group. Rama et al 19 also found an increase in total blood loss in the early release group but the late release group had significantly higher complications, with 3.1% returning to the operating room (OR) due to postoperative complications, compared with only one patient (0.3%) returning to the OR in the early release group (p ¼ 0.04).…”

Efficiency and Safety of Tourniquet During Total Knee Arthroplasty: When to Perform Release?

“…Так, Р. Zhang с соавторами, проведя анализ 16 исследований, пришли к выводу, что ранний релиз турникета (перед ушиванием операционной раны) статисти-чески значимо увеличивает объем периопераци-онной кровопотери, что в значительной степени нивелирует благоприятные эффекты использо-вания жгута, хотя в то же время выполнение ге-мостаза перед ушиванием операционной раны позволило уменьшить количество периопераци-онных осложнений, в первую очередь, -«малых инфекционных» [11]. сходные результаты были получены и в нашем исследовании, в котором группа пациентов с ранним релизом турникета показала худшие результаты по показателям сни-жения гемоглобина / эритроцитов / гематокрита и количеству эвакуированной во время пункций крови по сравнению с группой пациентов с позд-ним релизом жгута.…”

“…с одной стороны, использование пневмотур-никета до окончания полимеризации цемента, его ранний релиз и выполнение гемостаза, позволяют оценить степень кровоточивости мягких тканей и произвести коагуляцию поврежденных во вре-мя хирургического доступа кровеносных сосудов. с другой стороны, за счет эффекта постишемиче-ской гиперемии кровотечение бывает более зна-чимым, чем без использования жгута, и в течение короткого времени приводит к большому объему интраоперационной кровопотери [11]. Многие ав-торы, изучающие различные методики применения пневмотурникета, рекомендуют использовать его на протяжении всего оперативного вмешательства с ушиванием раны наглухо, без дренирования по-лости коленного сустава [12,13].…”

Minimizing Blood Loss and Transfusions in Total Knee Arthroplasty

“…Results have shown that preclosure release may lead to higher perioperative blood loss and longer operative time compared with postclosure release; however, the risk of complications was significantly decreased. [37][38][39] Rama et al found that tourniquet release after wound closure was associated with an increased rate of early postoperative complications requiring surgical intervention. 40 To date, neither method has been proven superior to the other with regard to TBL and major adverse events.…”