Thigh pain following tourniquet application in simultaneous bilateral total knee replacement arthroplasty

Thigh pain following tourniquet application is a common patient complaint in the early postoperative period following total knee arthroplasty. Postoperative thigh pain was evaluated in 28 consecutive simultaneous bilateral total knee arthroplasty patients between April 1996 and October 1996. A prospective, doubleblind, randomized clinical trial was performed. Tourniquet pressure of 350 mmHg was used on 1 thigh (thigh 1) and 100 mmHg plus systolic blood pressure on the other (thigh 2). A scale of pain (no pain, mild, moderate, or severe) was applied on the first, second, and third days, as well as 2 and 6 weeks after surgery. There were 16 men and 12 women with a mean age of 72 years (range, 55–85 years). The mean tourniquet time was similar in both groups (thigh 1 = 23 minutes, thigh 2 = 22 minutes). The mean tourniquet pressure in thigh 2 was 230 mmHg (range, 212–260 mmHg). There was a statistically significant difference in thigh pain on the first (P = .01), second (P = .01), and third (P = .001) postoperative days between both groups, with more thigh pain on the 350 mmHg side. At 6 weeks after surgery, the difference in thigh pain was gone. For total knee arthroplasty, using the tourniquet at a pressure of 100 mmHg above the systolic blood pressure is recommended. This is adequate to provide a bloodless field and will result in a less unpleasant postoperative period.     

评价全膝关节置换术中使用气囊止血带的作用

目的评价全膝关节置换（TKA）术中止血带使用时间的不同对患者的影响。方法收集106例行单侧TKA术患者资料,按入院时间段分为A组（53例）和B组（53例）,A组手术开始至结束全程使用了止血带,B组只在使用骨水泥过程中使用止血带。比较两组患者手术时间、出血量、术后各种并发症的发生率、术后住院天数的差异。结果与A组比较,B组患者手术时间长,术中出血量多,但术后出血量少,住院天数短,静脉血栓的发生率低,术后愈合不良的发生率低,总体失血量与A组相当。结论TKA术中减少止血带使用时间能降低术后并发症且无增加出血的危险。     

Timing of tourniquet release in total knee arthroplasty when using a postoperative blood salvage drain

The purpose of this study is to examine the effect of a postoperative blood salvage drain and timing of tourniquet release on the maximal hematocrit drop after total knee arthroplasty. Thirty-seven total knees were prospectively randomized into either an early or late tourniquet release group. Hematocrit drop and drainage amounts were recorded. We found no significant difference in maximal hematocrit drop, drainage amounts, or total surgical time between the groups. We conclude that the use of a blood salvage drain should not influence the surgeon's preference on timing of tourniquet release in total knee arthroplasty.     

A new tourniquet system that determines pressures in synchrony with systolic blood pressure in total knee arthroplasty

This study reports the comparison of the clinical use of a new tourniquet system for total knee arthroplasty that can determine its pressure in synchrony with systolic blood pressure (SBP) with the conventional that keeps the initial setting pressure. We prospectively applied the additional pressure of 100 mm Hg based on the SBP recorded before skin incision to consecutive 72 procedures (conventional, initial 36; new, following 36). Six knees with the conventional and none of 5 with the new showed oozing blood in surgical field after sharp rise in SBP. Based on no statistically significant differences of the perioperative blood loss without any tourniquet-related postoperative complications in both groups, the new system seemed to be a practical device especially for controlling a bloodless surgical field.     

A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

A tourniquet is often used in total knee arthroplasty resulting in improved visualization of structures, reduced intraoperative bleeding and better cementation. The risks include deep vein thrombosis and pulmonary embolism. To quantify the case for or against tourniquet use, we carried out a systematic review and meta-analysis of selected randomized controlled trials. Ten studies were included in the meta-analysis. Of the 8 outcomes analyzed (surgery duration; total, intraoperative, and postoperative blood losses; deep vein thrombosis; pulmonary embolism; and minor/major complications), the total and intraoperative blood losses were less using a tourniquet. Minor complications were more common in the tourniquet group. The remaining outcomes showed no difference between the groups. Using a tourniquet may be beneficial, but long-term studies of outcome are needed.     

气压止血带在膝关节置换术中应用的研究进展

气压止血带通过充气加压袖带压迫肢体近端动脉以达到手术区域止血的效果.膝关节置换术中使用气压止血带可以获得优质的手术视野、无血的操作区域以及良好的假体置入环境.但随着现代医学的不断发展,气压止血带使用所带来的各种并发症不断被挖掘与重视.如何更加精确地使用气压止血带,发挥其优势并规避风险,已成为气压止血带研究的主要方向.该...     

Total knee arthroplasty using the total condylar III knee prosthesis

Twenty-seven total knee arthroplasties (TKAs) were performed in 24 patients using the total condylar III knee prosthesis (TCP III) and were evaluated clinically and radiographically with a mean follow-up period of 4 years. Eighteen were revision TKAs, and nine were primary knee arthroplasties. Evaluations were made using the Hospital for Special Surgery (HSS) knee scale as well as the Knee Society radiographic evaluation method. Clinical results for all knees were 11% (3 of 27) excellent, 70% (19 of 27) good, 15% (4 of 27) fair, and 4% (1 of 27) poor. The one poor rating resulted from an intraoperative vascular injury. The results showed no statistical difference between revision and primary TKA. After operation, pain relief, range of motion, walking, function, and activity level improved in both the primary and revision patients. Radiolucencies 2 mm or greater in width were found in 6 of the 27 tibial components, in none of the 27 femoral components, and in 1 of the 19 patellar components. Only two tibial implants showed progressive radiolucencies. No correlation was found between the radiographic position of the implants and the clinical results. The authors conclude that the TCP III is a satisfactory choice for TKA in selected knees in which there is significant instability and in which intramedullary fixation is required.     

不同干预措施对全膝关节置换术围手术期出血的影响

目的探讨止血带松开时机和引流管夹闭对全膝关节置换术(TKA)围手术期出血的影响。方法将70例单膝TKA治疗的膝骨关节炎患者分别采用术中关闭伤口前电凝止血后松开止血带、术后夹闭引流管6h(观察组,40例)和术中全程使用止血带、术后引流管处于自然开放引流状态(对照组,30例),观察两者的出血量及下肢静脉血栓形成情况。结果观察组术中出血量明显多于对照组(P0.05),但术后引流量、隐性失血量及总失血量均明显小于对照组(P0.05)。输血例数及输血量:观察组11例(27.5%),平均输血量2.7 U;对照组24例(80.0%),平均输血量3.4 U;两组比较差异有统计学意义(P0.01)。术后深、浅静脉血栓形成例数:观察组5例(12.5%),对照组1例(3.3%),但差异无统计学意义(P0.05)。结论术中闭合伤口前电凝止血后松开止血带、术后夹闭引流管6 h能够明显减少TKA围手术期的总出血量,但能增加下肢静脉血栓形成。     

全膝关节置换术中不同时机释放止血带比较的Meta分析

[目的]应用Meta分析的方法,评价全膝关节置换术(totalkneearthroplasty,TKA)中关闭伤口前松开止血带电凝止血和关闭伤口并敷料包扎后松开止血带对失血量及手术并发症的影响.[方法]计算机检索Pubmed、EM-BASE、Ovid和Cochrane图书馆关于TKA术中对不同时机释放止血带进行比较的随机对照试验,按照文中所述纳入标准收集后进行比较,利用RevMan5.0软件进行异质性分析及Meta分析,绘制森林图.[结果]作者检索了1979～2010年间发表的198篇关于TKA术中应用止血带的文献,经过筛选和评价,最后收集到已发表的9篇(共526例患者)随机对照试验,符合本次Meta分析所纳入的试验标准.结果发现关闭伤口并敷料包扎后松开止血带组患者围手术期失血量和手术时间显著少于关闭伤口前松开止血带组,但后者可以显著减少术后相关并发症发生率.[结论]关闭伤口前松开止血带电凝止血方法可以减少TKA术中止血带应用时间而降低术后并发症发生率,但增加围手术期失血量.     

Two-stage conversion of fused knee to total knee arthroplasty

We report 2 cases of conversion of fused knee to total knee arthroplasty (TKA) by way of soft-tissue expansion. Case 1 had had multiple operations on the infected total knee, which was arthrodesed 7 months before conversion. Case 2 had had knee arthrodesis for an intra-articular comminuted fracture 5 years and 10 months before conversion. In both patients, a tissue expander was placed subcutaneously upon the patella and the patellar tendon to gradually expand the anterior knee skin for later coverage and knee flexion. After takedown of the arthrodesis, a fully constrained rotating-hinge prosthesis was implanted as the second-stage procedure. The final range of flexion was 95 degrees in both knees with patients' subjective satisfaction.     

半程使用止血带对全膝关节置换术围手术期失血量和早期功能恢复的影响

目的探讨半程使用止血带对全膝关节置换术（TKA）围手术期失血量和早期功能恢复的影响。方法设计前瞻性随机对照研究,将64例符合纳入条件的患者随机分为2组：半程使用止血带32例（半程组）,全程使用止血带32例（全程组）。记录围手术期失血量,术后1、3、7 d大腿及膝关节VAS疼痛评分,术后至能完成直腿抬高和屈膝90°的时间,下肢深静脉血栓发生率,并进行组间比较。结果半程组术中失血量（257.8±105.1）ml,稍高于与全程组的（213.8±87.4）ml,但差异无统计学意义（P〉0.05）;半程组术后引流量（195.3±89.1）ml,低于全程组的（280.2±114.5）ml,差异有统计学意义（P〈0.05）;半程组预估失血量（561.0±165.1）ml,也低于全程组的（673.0±201.3）ml,差异有统计学意义（P〈0.05）。半程组大腿肿胀率低于全程组,术后第3天组间差异有统计学意义（P〈0.05）。半程组完成直腿抬高的时间（1.5±0.9）d,早于全程组的（1.9±1.1）d,差异无统计学意义（P〉0.05）;半程组完成屈膝90°的时间（1.8±1.1）d,也早于全程组的（2.7±1.2）d,差异有统计学意义（P〈0.05）。结论 TKA术中半程使用止血带能减少围手术期失血量,并可改善患肢早期疼痛评分及肿胀程度,有利于患者早期功能恢复。     

Changes in coagulation-fibrinolysis marker and neutrophil elastase following the use of tourniquet during total knee arthroplasty and the influence of neutrophil elastase on thromboembolism

BACKGROUND: To clarify in detail the mechanism underlying the development and exacerbation of deep venous thrombosis (DVT) and/or pulmonary thromboembolism (PTE), we focused on the following factors: the thrombin-antithrombin III complex (TAT), D-dimer and neutrophil elastase (NE). We basically investigated whether NE played an important role in the development of PTE I a mice model. METHODS: Nineteen rheumatoid arthritis (RA) and six osteoarthritis (OA) patients underwent total knee arthroplasty (TKA) with tourniquet, and 13 RA and 12 OA patients underwent TKA without tourniquet in each group. The blood levels of TAT, D-dimer and NE were measured before surgery, immediately after and during the days following surgery. For the induction of experimental PTE due to coagulation of platelets, adenosine diphosphate (ADP) was administrated, and human NE with ADP was also administrated for the development of DVT and/or PTE. RESULTS: The rates of increase in the mean TAT, D-dimer and NE levels in the group with tourniquet were statistically higher than those in the group without tourniquet after surgery. The mortality of the mouse due to PTE increased from 43 to 67% following ADP and human NE administration compared to a single ADP administration. Histological changes of the lungs in the mice receiving NE and ADP injections were characterized by a diffuse and extensive accumulation of platelets and fibrin in alveolar capillaries and other microvessels. CONCLUSION: We suggest that during TKA, the use of tourniquet induces local release of a large amount of NE from neutrophils, inducing the development of DVT and/or PTE and their exacerbation.     

止血带使用时间与全膝关节置换术肺脂肪栓塞风险的实验研究

[目的]探讨全膝关节置换术中止血带的使用与肺脂肪栓塞产生的相关性。[方法]32只健康犬随机分为四组,A组:模拟全膝关节置换术,截骨、扩髓,插入髓内杆,术中使用止血带60 min;B组:操作同A组,术中使用止血带90 min;C组:术中操作同A组,术中不使用止血带;D组:术中仅使用止血带60 min,不模拟全膝关节置换。术中监测不同时间动脉血气分析和凝血指标,术后进行肺脏病理检查并采用病理学评分计算肺损伤程度。统计分析采用卡方检验和非参数检验。[结果]不考虑时间因素时,止血带90 min组与其余组比较,PaO2差异显著(F=3.013,P=0.047),考虑时间因素时,止血带90 min组在术毕和术后5 min时,Pa O2差异亦显著(F=3.427,P=0.029)。PaCO2各组间在术中术后无统计学差异。凝血指标中两组各时间点PT、APTT无显著差异(F=0.616,P=0.61)。肺组织病理切片显示:肺损伤总分止血带90 min组高于其余各组(x2=19.996,P=0.001)。[结论]全膝关节置换术后止血带释放时可能干扰呼吸系统功能,增加肺脏脂肪栓塞的发生风险,尤其在止血带使用时间达到90 min时。     

Recurrent hemarthrosis after total knee arthroplasty

Seven patients developed recurrent hemarthroses following total knee arthroplasty. The average interval between arthroplasty and the first bleed was more than 20 months (range, 1–30 months). All seven required open synovectomy an average of 21 months (6–31 months) after arthroplasty. Follow-up evaluation averaged 44 months (19–60 months) and all had an excellent result without further bleeds. A prolific synovitis was seen in all cases, with histologic features revealing a chronic synovitis with fibrosis and hemosiderin staining. Entrapment of the proliferative synovial tissue between the components is postulated to be the etiology for these recurrent bleeds which averaged four per patient prior to synovectomy.     

Dislocation following primary posterior-stabilized total knee arthroplasty

From 1981 through 1991, 3, 032 primary total knee arthroplasties were performed using the Insall-Burstein Posterior Stabilized Condylar Prosthesis (IB-I, IB-II, and IB-II modified) (Zimmer, Warsaw, IN). Fifteen posterior dislocations occurred: 4 with the IB-I system occurring 2 or more years after surgery, 10 with the IB-II system (8 occurring 6 months after surgery and 2 occurring 2–3 years after surgery), and 1 with the IB-II modified system occurring 9 months after surgery. Statistically significant differences for the rate of dislocation between both the IB-I and IB-II modified arthroplasties versus the IB-II arthroplasties were found (P < .001). In an attempt to identify a cause for these dislocations, the authors retrospectively assessed the 15 dislocated cases with respect to sex, age, weight, height, preoperative and postoperative Hospital for Special Surgery scores, preoperative and postoperative alignment, preoperative versus postoperative reconstruction dimensions, patellar thickness and height, and postoperative flexion and compared the results with those patients who did not experience dislocation. Possible etiologies and mechanisms of dislocation were sought. There were no significant differences between the control and study groups for any variable assessed, with the exception of postoperative flexion, which averaged 118° for the study group and 105° for the control group (P < .001). Conservative management was successful in 11 cases. In September 1988 the IB-II system was introduced; modification of the tibial insert was made in January 1990. The 10 IB-II dislocations occurred prior to the modification of the modular tibial polyethylene insert, and the 3 recurrent dislocations in this group were successfully treated with revision to this modified insert. Since this modification, 656 IB-II modified systems have been implanted with one dislocation (0.15%).     

Patello-femoral complications associated with total knee arthroplasty

The patello-femoral articulation accounts for a significant number of the complications that occur after total knee replacements and which require re-operation. These include problems with stability, component wear, fracture, loosening, and osteonecrosis. With careful attention to prosthetic design and surgical technique, these complications can be minimized. Guest Lecture presented at the 26th meeting of the Japanese Society for Replacement Arthroplasty in Tokyo on February 2, 1996     

Osteolysis after total knee arthroplasty

Osteolysis ranks as the most significant cause of revision surgery in both total hip arthroplasty and total knee arthroplasty (TKA). The factors leading to osteolysis in TKA are unique and sometimes preventable. Changes in polyethylene manufacturing and implant design are striving to improve overall wear. In this review, we discuss osteolysis as it relates to TKAs. The etiology, diagnosis, contributing factors, and management are presented. The final section focuses on future improvements in TKA design, which may ultimately decrease the rate of osteolysis.     

Results of contralateral total knee arthroplasty in patients with a history of stiff total knee arthroplasty

This study seeks to evaluate the clinical outcomes of a second primary total knee arthroplasty in patients whose initial (contralateral) primary total knee arthroplasty was complicated by stiffness. We retrospectively compared the preoperative and postoperative range of motion and Knee Society Scores from a study group of 15 patients with an age-matched control group. Statistical analysis did not reveal a significant difference in final postoperative range of motion or Knee Society Scores between the 2 groups. However, there was a statistically significant higher rate of closed manipulation in the study group. Therefore, although the study group did show a higher rate of early stiffness, eventual functional outcome was comparable with a nonstiffness control group.     

人工全膝关节表面置换术治疗重症膝关节病

目的　探讨人工全膝表面置换术 (TKA)治疗重症膝关节病的疗效。方法　采用TKA共治疗 21例 24膝,其中晚期骨性关节炎 15例 17膝,类风湿关节炎 4例 5膝,全膝关节结核 2例 2膝。按TKA原则施术,重建膝关节负重力线,截骨达到伸屈间隙相等,维护软组织平衡,保持髌骨中置位,获取膝关节充分活动度。结果　平均随访 2 5年,膝关节平均活动度由术前的 58°(30°~100°)改善到 96°(60°~120°),疼痛、跛行明显改善,无感染。结论　对疼痛、畸形、明显影响功能、年龄在 60岁以上的重症膝关节病患者选择TKA治疗,疗效满意。     

Intraoperative passive knee kinematics during total knee arthroplasty surgery

Surgical navigation systems for total knee arthroplasty (TKA) surgery are capable of capturing passive three‐dimensional (3D) angular joint movement patterns intraoperatively. Improved understanding of patient‐specific knee kinematic changes between pre and post‐implant states and their relationship with post‐operative function may be important in optimizing TKA outcomes. However, a comprehensive characterization of the variability among patients has yet to be investigated. The objective of this study was to characterize the variability within frontal plane joint movement patterns intraoperatively during a passive knee flexion exercise. Three hundred and forty patients with severe knee osteoarthritis (OA) received a primary TKA using a navigation system. Passive kinematics were captured prior to (pre‐implant), and after prosthesis insertion (post‐implant). Principal component analysis (PCA) was used to capture characteristic patterns of knee angle kinematics among patients, to identify potential patient subgroups based on these patterns, and to examine the subgroup‐specific changes in these patterns between pre‐ and post‐implant states. The first four extracted patterns explained 99.9% of the diversity within the frontal plane angle patterns among the patients. Post‐implant, the magnitude of the frontal plane angle shifted toward a neutral mechanical axis in all phenotypes, yet subtle pattern (shape of curvature) features of the pre‐implant state persisted. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:1611–1619, 2015.