Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism

Migliorini, Filippo; Maffulli, Nicola; Eschweiler, Jörg; Knobe, Matthias; Tingart, Markus; Betsch, Marcel

doi:10.1016/j.surge.2021.03.004

Cited by 11 publications

(7 citation statements)

References 90 publications

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“…Xie et al, in a meta-analysis of 14 randomized controlled trials reported that tourniquet use doubled the risk of postoperative VTE compared to no tourniquet use 418 . Similarly, Migliorini et al, in their meta-analysis including both randomized and non-randomized studies found that tourniquet use increased the risk of postoperative VTE four-fold, but this increase was of borderline statistical significance 426 . Two meta-analyses also reported an increased risk of postoperative VTE with use of a tourniquet 417,423 .…”

Section: - Should the Use Of Lower Extremity Tourniquet Be Avoided In...mentioning

confidence: 91%

“…In contrast, several meta-analyses have reported no difference in VTE rates between patients who had tourniquet use and no tourniquet use during TKA 424,426 . Cai et al, included 541 TKA from 11 randomized controlled trials and found no difference in VTE rates between patients who had tourniquets and those that did not 424 .…”

Section: 45% (Strong Consensus)mentioning

confidence: 95%

“…Several meta-analyses investigating the association between tourniquet use and the incidence of VTE postoperatively have yielded mixed results [417][418][419][423][424][425][426] . Xie et al, in a metaanalysis of 14 randomized controlled trials reported that tourniquet use doubled the risk of postoperative VTE compared to no tourniquet use 418 .…”

Section: 45% (Strong Consensus)mentioning

confidence: 99%

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Recommendations from the ICM-VTE: Hip & Knee

2022

Journal of Bone and Joint Surgery

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The ICM-VTE Hip & Knee Delegates* 1 -Is VTE after elective total joint arthroplasty a "never event"?Response/Recommendation: Venous thromboembolism (VTE) after elective total joint arthroplasty (TJA) continues to occur despite various strategies in prophylaxis and should not be considered a "never event."Strength of Recommendation: Moderate.Delegates vote: Agree 94.87% Disagree 5.13% Abstain 0.00% (Strong Consensus).Rationale: As part of an initiative to address quality of care and control healthcare costs, in 2002, the United States Centers for Medicare and Medicaid Services (CMS) defined "never events" as hospital-acquired conditions that were considered reasonably preventable 1 . In 2008, CMS added deep venous thrombosis (DVT) and pulmonary embolism (PE) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) 2 .Historically, DVT and PE were important risks for patients undergoing TJA. In a study of 7,959 patients between 1962 and 1973, Charnley et al., reported a non-fatal PE rate of 7.89% and a 1.04% rate of fatal PE which constituted the highest single cause of death after a THA 3 . Coventry et al., identified a cohort of 2012 THA from 1969 to 1971 of which 58 did not receive chemoprophylaxis past post-operative day five and observed a DVT rate of 3.4%, a non-fatal PE rate of 5.2%, and a fatal PE rate of 3.4% 4,5 . In a series performed between 1990 and 1991, Warwick et al., identified 1,162 patients undergoing THA without routine chemoprophylaxis, with DVT confirmed by venography in 1.89% of patients and a PE rate of 1.20% with a subsequent mortality rate of 0.34% 6 .Early studies demonstrated a much higher incidence of VTE for TKA 7,8 . However, DVT in TKA patients occur distally in the calf which are less likely to progress into a PE which was observed at a rate of 1.3% 9 with fatalities of 0.19 to 0.4% 9,10 . Stulburg et al., examined a series of 638 patients from 1974 to 1979 among which 49 patients inadvertently did not receive prophylaxis; an impressive 83% of these patients developed a DVT 11 .In a prospective study with 34,397 consecutive and unselected THA or TKA procedures, 32 (0.09%) had a VTE after median two days despite ongoing thromboprophylaxis 12 . All surgery was done in a fast-track setup with accelerated mobilization and discharge. Another study has shown a 90-day incidence of 0.41% of VTE after unicompartmental knee arthroplasty 13 . All patients received thromboprophylaxis until discharge and were operated in a fast-track setup with a median length of stay of one day.With VTE as a common and potentially dangerous complication after TKA and THA, safe and effective strategies for prophylaxis were developed and studied. When warfarin dosage is titrated to an international normalized ratio (INR) of 1.5 to 2.0 and administered for approximately six weeks, DVT occurred at a rate of 0.2 to 1% with a non-fatal PE rate of 0.1 to 0.3% [14][15][16] . Warfarin was found to consistently decreased rates of VTE when utilized after THA or TKA, but may lead to a significant risk ...

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Section: - Should the Use Of Lower Extremity Tourniquet Be Avoided In...mentioning

confidence: 91%

Section: 45% (Strong Consensus)mentioning

confidence: 95%

Section: 45% (Strong Consensus)mentioning

confidence: 99%

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Recommendations from the ICM-VTE: Hip & Knee

2022

Journal of Bone and Joint Surgery

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“…Tourniquet was used during knee surgical procedures because of its haemostatic function [8,9]. However, the recent literature that is full of controversy has raised controversy over its use [10][11][12][13][14]. In addition, it may be associated with an increased risk of serious adverse events, pain, and a rising more extended hospital stay [15,16].…”

Section: Introductionmentioning

confidence: 99%

Peri-articular administration of tranexamic acid is an alternative route in total knee arthroplasty: a systematic review and meta-analysis

Fan

Liu

et al. 2022

J Orthop Surg Res

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Background As an antifibrinolytic agent, tranexamic acid (TXA) is increasingly used in total knee arthroplasty (TKA) to reduce blood loss. The administration of intravenous and intra-articular TXA has been well explored, but the most efficient way to administer TXA remains in question. Peri-articular injection (PAI) of TXA is a recently mentioned method. A meta-analysis of the efficacy of PAI TXA in patients after TKA should be performed. Methods A systematic search was performed within PubMed, Embase, and the Cochrane Library up to November 8, 2021. Two authors independently screened studies for eligibility and extracted data for analysis. The primary outcome was haemoglobin change. The secondary outcomes were haematocrit change, total drainage volume, thromboembolic events, and blood transfusion. Results A total of ten studies were included in this meta-analysis. The results indicated that there was a significant decrease in haemoglobin change when using PAI TXA compared with no TXA (mean difference − 1.05; 95% CI − 1.28 to − 0.81; P < 0.00001; I2 = 0%), but it had no significant differences compared with IA and IV (mean difference − 0.01; 95% CI − 0.17 to − 0.14; P = 0.85; I2 = 39%). There were no significant differences between the TXA < 1.5 g subgroup (0.10, 95% CI − 0.27 to 0.46; P = 0.60; I2 = 0%) and the TXA ≥ 1.5 g subgroup (0.18, 95% CI − 0.12 to 0.48; P = 0.24; I2 = 74%). In addition, the combined group (PAI plus IV or IA) was superior to the IV or IA group in terms of haemoglobin change (mean difference − 0.51; 95% CI − 0.76 to − 0.27; P < 0.0001; I2 = 19%). Regarding haematocrit change, the pooled result showed it was significantly less in the PAI group than the non-TXA group. Similarly, comparing it against the IV subgroup, the result revealed a difference in favour of the PAI group, with a mean difference of − 1.89 g/dL (95% CI − 2.82 to − 0.95; P < 0.0001; I2 = 67%). For total drainage volume, the pooled result was in favour of PAI TXA over no TXA (297 ml, 95% CI − 497.26 to − 97.23; P = 0.004; I2 = 87%), but it had no significant difference compared with IA and IV (mean difference − 37.98; 95% CI − 115.68 to 39.71; P = 0.34; I2 = 95%). There was no significant difference in thromboembolic events (OR 0.74; 95% CI 0.25 to 2.21; P = 0.59; I2 = 0%). Blood transfusion was not significantly different between the PAI group and the non-TXA group (OR 0.50; 95% CI 0.23 to 1.06; P = 0.07; I2 = 21%), and there was no significant difference between PAI and the other two TXA injection methods (OR 0.72; 95% CI 0.41 to 1.25; P = 0.24; I2 = 19%). Conclusion PAI has comparable effects to IV and IA injections. PAI is an alternative injection route of TXA for patients who have undergone TKA.

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“…However, this procedure is associated with several complications. Soft tissue damage may occur because of excessive inflation pressure and duration, including damage to the skin, vessels, muscles, and nerves, ischemia/reperfusion injury, and thromboembolism [5][6][7][8][9]. As there are no evidence-based guidelines for the use of tourniquets in clinical settings, an objective method is required to determine an optimal tourniquet protocol that enhances visualization and minimizes potential tissue injury.…”

Section: Introductionmentioning

confidence: 99%

Measurement of tissue oxygen saturation during arthroscopic surgery of knee with a tourniquet

et al. 2022

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Background Tourniquets provide better tissue visibility during arthroscopic surgery. However, multiple postoperative adverse events associated with ischemia may be caused by excessive inflation pressure and duration. We aimed to evaluate the degree of tourniquet-induced ischemia using a noninvasive continuous real-time monitoring method and the relationship between changes in tissue oxygen saturation (StO2) and blood biochemical markers of ischemic injuries in patients undergoing arthroscopic knee surgery. Methods This was a prospective observational study using near-infrared spectroscopy (NIRS). Data were collected from 29 consecutive patients who underwent arthroscopic procedures. Twenty-five patients underwent anterior cruciate ligament reconstruction, and four underwent meniscal repair. We investigated tourniquet‐induced changes in StO2, monitored using NIRS, and blood biochemical markers of ischemic injuries. Results A significant decrease in the mean StO2 from the baseline was observed during tourniquet inflation in the operative legs. The average decrease in the mean StO2 was 58%. A comparison of mean StO2 between the nonoperative and operative legs before tourniquet deflation showed that mean values of StO2 in the operative legs were significantly lower than those in the nonoperative legs. No significant clinical relationships were observed between changes in StO2 and blood biochemical markers of ischemic injuries (creatine kinase) (p = 0.04, r = 0.38) or tourniquet duration (p = 0.05, r = 0.366). Conclusions Our results demonstrated that StO2 could be used to evaluate tissue perfusion in real time but did not support the hypothesis that StO2 is a useful method for predicting the degree of tourniquet-induced injury during arthroscopic knee surgery.

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Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism

Cited by 11 publications

References 90 publications

Recommendations from the ICM-VTE: Hip & Knee

Recommendations from the ICM-VTE: Hip & Knee

Peri-articular administration of tranexamic acid is an alternative route in total knee arthroplasty: a systematic review and meta-analysis

Measurement of tissue oxygen saturation during arthroscopic surgery of knee with a tourniquet

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