The limited use of a tourniquet during total knee arthroplasty: A randomized controlled trial

BackgroundTotal knee arthroplasty (TKA) is commonly performed using a tourniquet. However, some studies have reported that several complications were associated with the use of a tourniquet in TKA. In this study we investigate whether the limited use of a tourniquet in TKA would reduce complications and facilitate postoperative recovery.MethodsSixty patients were randomly divided into two groups (30 cases/group): group A using the tourniquet throughout the surgical procedure, and group B using the tourniquet starting from the cementation to the completion of the procedure. Operation time, total measured blood loss, and incidence of complications were all recorded.ResultsThere was no significant difference in operation time, total measured blood loss, and hemoglobin concentration between the two groups. Incidence of postoperative complications in group B was significantly decreased in comparison to that in group A. The limb circumference at 10 cm above the superior patellar pole or below the inferior patellar pole and the pain score in group B were significantly decreased compared with that in group A at any time point. Range of motion in group B was significantly increased at three and 5 days postoperatively in comparison to that in group A.ConclusionsThe limited use of a tourniquet in TKA provides the benefit of decreased limb swelling and knee joint pain while not compromising the operation time or blood loss and recovery.Level of evidenceLevel I (Therapeutic).Trial registration numberNCT02102581.     

The effect of tourniquet release timing on perioperative blood loss in simultaneous bilateral cemented total knee arthroplasty: a prospective randomized study.

Today the use of pneumatic tourniquet is commonly accepted in total knee arthroplasty (TKA) to reduce perioperative blood loss. There are a few prospective randomised and nonrandomised studies that compare the effect of tourniquet release timing in cementless or cemented unilateral TKA. However, many of these studies show an inadequate reporting and methodology. This randomized prospective study was designed to investigate the efficiency of tourniquet release timing in preventing perioperative blood loss in a simultaneous bilateral TKA study design. To our knowledge, this is the first study of its kind, in which the effect of tourniquet release timing on perioperative blood loss was investigated in simultaneous bilateral cemented TKA to compare both techniques intraindividually. In 20 patients (40 knees) one knee was operated with tourniquet release and hemostasis before wound closure, and the other knee with tourniquet release after wound closure and pressure dressing. We found no significant difference in total blood loss between both techniques (p=0.930), but a significant difference in operating time (p=0.035). There were no postoperative complications at a follow-up of 6 month. Other studies report an increase the blood loss in early tourniquet release and an increase the risk of early postoperative complications in deflation of tourniquet after wound closure. In this study we found no significant difference in perioperative blood loss and no increase of postoperative complications. Therefore, we recommend a tourniquet release after wound closure to reduce the duration of TKA procedure and to avoid possible risks of extended anaesthesia.     

骨水泥型全膝关节置换术中止血带应用策略的研究

目的对比研究不同止血带策略在骨水泥型全膝关节置换术中应用的安全性和有效性。方法从2014年3月到2017年3月,回顾性分析131例接受初次单侧骨水泥型全膝关节置换术的患者,按照止血带使用时间分为对照组和实验组。对照组包含72名病人,在假体安装完成后切口缝合完全止血前松开止血带,而实验组的59名病人在切口缝合,患肢用弹性绷带包扎后松开止血带。本研究分析相关临床数据,包括手术时间、止血带时间、显性失血量、隐性失血量、血红蛋白降低和术后并发症。结果对照组和实验组的显性失血量分别为(750.6±91.4)m L和(615.2±52.1)mL(P<0.05);隐性失血量分别为(751±252)mL和(532±281)mL(P<0.05)。对照组有明显的显性及隐性失血量增加(P<0.05)。对照组和实验组分别出现9例和13例轻微并发症,两组之间没有统计学差异(P=0.15),此外两组病人均未出现严重并发症。结论全膝置换手术全程应用止血带可以明显减少显性及隐性失血量,并且没有明显增加感染、皮缘坏死、下肢水肿和深静脉血栓等并发症的风险。     

全膝关节置换术中限制性使用止血带的临床效果观察

目的探讨限制性使用止血带对全膝关节置换(Total knee arthroplasty,TKA)术后并发症发生率及膝关节早期活动度的影响。方法选取2015年9月~2016年5月120例在我院行初次单侧TKA患者,采用随机分类方法将其分为A、B、C 3组,每组40例。试验组A采用充气止血带术前驱血加压至手术切口关闭加压包扎后再松止血带,即全程使用止血带;试验组B采用截骨时驱血加压至假体安装完毕骨水泥完全凝固后放松止血带,即限制性使用止血带;对照组C全程不使用止血带。比较3组患者平均手术时间、术中失血量、术后引流量、隐性失血量、总失血量、软组织损伤发生率、血栓并发症发生率、术后早期关节活动度(Range of motion,ROM)。结果 A、B两组术中失血量均少于C组,差异有统计学意义(0.05);A、B、C三组手术时间、总失血量比较,差异无统计学意义(0.05);B、C两组软组织损伤发生例数均少于A组,差异有统计学意义(0.05);A、B、C三组患者均未发现症状性深静脉血栓(Deep venous thrombosis,DVT)和肺栓塞(Pulmonary embolism,PE)。A、B、C三组术后第1、7天,活动度无统计学差异(0.05),第3、5天,B、C两组膝关节活动度大于A组(0.05),差异有统计学意义。结论在TKA手术中,限制性使用止血带可缩短手术时间,减少术后并发症,有助于膝关节术后早期功能活动。     

Femoral component rotations in different gap tensions in total knee arthroplasty: A prospective randomized controlled trial

Background

In total knee arthroplasty (TKA), femoral component rotation is an important factor in the flexion stability and biomechanics of the patellofemoral joint. However, it remains unclear how much tension is appropriate when performing TKA using the gap technique.

全膝关节置换后系统康复的随机对照

背景：国内外对人工全膝关节置换后的康复有较多的研究,但往往局限于一种康复方法。 目的：分析系统康复对人工全膝关节置换后康复进程的影响。 方法：选择行单侧人工全膝关节置换的50例骨性关节炎患者,随机分为两组,干预组置换前给予康复指导,置换后由康复治疗师给予康复锻炼,同时行CPM锻炼和冷敷,对照组给予传统CPM锻炼。 结果与结论：干预组置换后24 h~6 d疼痛目测类比评分均低于对照组(P < 0.05),置换后2 d~6周时膝关节活动度高于对照组(P < 0.05),置换后2,6周时HSS评分高于对照组(P < 0.05),两组均无局部切口并发症发生。说明人工全膝关节置换后系统康复可加快康复进程,减轻患者疼痛,改善关节活动度,且不会增加并发症。     

人工全膝关节置换后是否放置引流管：随机对照试验

BACKGROUND: Total knee arthroplasty had been generally accepted as the final treatment plan, relieving pain and reconstructing function of knee joint. However, whether drainage tube can be used after replacement is still controversial.     

Evaluation of wound healing after total knee arthroplasty in a randomized prospective trial comparing fondaparinux with enoxaparin

BACKGROUND: Fondaparinux, a new synthetic pentasaccharide has proven to be a more potent thromboprophylactic drug compared to enoxaparin after major orthopaedic surgery. However, the safety of fondaparinux regarding wound healing has not yet been investigated. METHODS: We performed a single-centre prospective clinical trial, in which patients undergoing total knee arthroplasty or revision of at least one of the components of a previous knee arthroplasty were randomly assigned to thromboprophylaxis with fondaparinux or enoxaparin. The trial included 109 patients and wound discharge was compared. Secondary outcome measures were the amount of blood in the suction drain, postoperative transfusion rate, change in haemoglobin levels, haematocrit, intervention rate, time to regain flexion and rate of symptomatic thromboembolic events. RESULTS: 55 patients were treated with fondaparinux and 54 with enoxaparin. Base-line characteristics were similar. In both groups wound dressings remained dry after five (5.17+/-2.5 and 5.19+/-3) days postoperatively. There were no significant differences in any of our outcome measures. CONCLUSIONS: We did not find any significant difference in wound healing with fondaparinux after major knee surgery. Post hoc analyses suggested the study should have had a sample size of 155 in each group. We believe this trial should be used as a pilot study for further investigations concerning the safety of thromboprophylaxis.     

The effectiveness of minimally invasive total knee arthroplasty to preserve quadriceps strength: A randomized controlled trial

We performed a single-center, randomized, double-blind study to compare muscle strength in patients who had undergone primary total knee arthroplasty (TKA), performed using either a minimally invasive or a conventional surgical technique. We evaluated 30 knees in healthy age-matched subjects, 22 knees after conventional TKA (conventional group), and 23 knees after minimally invasive surgery TKA (MIS group). The Hospital for Special Surgery (HSS) score, Oxford knee score (OKS), and isokinetic (60º/s) muscle strength were evaluated the day before surgery and 3, 6, and 12 months after surgery. HSS and OKS improved significantly over time during follow-up (p < 0.001), but there was no significant difference between the groups (p > 0.05). The extensor peak torque (EPT) and flexor peak torque (FPT) improved significantly over time (p < 0.001) and EPT was greater in the MIS group than in the conventional group during the follow-up period (p < 0.05). There was no difference in FPT and the hamstring-to-quadriceps ratio between the groups. Although MIS patients had a significant deficit in extensor strength following TKA, compared with healthy controls, this approach offers a significant improvement in extensor muscle strength over conventional surgery. These results suggest that the MIS approach results in better outcomes with regard to maintaining extensor strength than the conventional surgical approach.     

同期双侧全膝关节置换中止血带的使用策略

背景：止血带在双侧膝关节置换中通常被全程使用或双侧部分时间使用,但极少有人尝试一侧不使用,对侧部分时间使用。 目的：探讨在同期双侧全膝关节置换术中可行有效的止血带使用策略。 方法：纳入2013年1至12月解放军医学院骨科收治的双膝重度骨关节炎患者80例(160膝),施行初次同期双膝置换,按先左后右顺序施行,按照止血带使用策略将分为两组,每组40例。试验组左膝不用止血带,右膝部分时间使用止血带;对照组双侧均全程使用止血带。记录两组患者术中及置换后失血量,置换后3 d大腿肿胀率及疼痛目测类比评分,置换后3周及1年后膝关节功能美国膝关节协会评分。 结果与结论：两组患者围手术期总失血量差异无显著性意义(P > 0.05),但是试验组患者置换后失血量少于对照组(P < 0.05)。试验组患者置换后3 d疼痛目测类比评分明显低于对照组(P < 0.05),试验组患者置换后3 d左侧疼痛目测类比评分低于右侧(P < 0.05);试验组患者置换后3 d双侧大腿肿胀率明显低于对照组(P < 0.05),试验组左侧置换后3 d大腿肿胀率低于右侧(P < 0.05);早期美国膝关节协会评分试验组高于对照组,远期评分两组差异无显著性意义(P > 0.05)。提示同期双侧全膝关节置换中采用先置换侧不使用止血带后置换侧部分时间使用止血带的策略,可在不增加围手术期总失血量的情况下减轻置换后疼痛及肿胀,促进膝关节早期功能恢复。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty — A randomized controlled trial

In a randomized, double-blind, placebo, parallel and controlled study, 80 patients with osteoarthritis who underwent unilateral TKA were randomly assigned to two groups: Trial Group, where patients received intra-articular intraoperative injection containing morphine, bupivacaine and betamethasone, and Control Group, where patients received normal saline as control. All patients received patient-controlled analgesia (PCA) for 48 h postoperatively. We found that intra-articular cocktail analgesic injection significantly reduced the morphine consumption during the 0–36 h postoperative period and the total morphine consumption. VAS at rest in Trial Group at postoperative 6, 10, 24 and 36 h was significantly lower than that in Control Group, and VAS during activity in Trial Group at postoperative 24 h and 36 h was significantly lower than that in Control Group. The time of ability to perform an active straight leg raise and to actively reach 90° knee flexion, as well as ROM of the knee at the 15th postoperative day, was better in Trial Group than those in Control Group. There were no significant differences in postoperative wound healing, infection, blood pressure, heart rate, rash, respiratory depression, urine retention and DVT between the two groups. The occurrence of nausea and vomiting in Trial Group was lower than that of Control Group. This study revealed that intra-articular cocktail analgesic injection reduced the need for morphine and offered a better pain control, without apparent risks following TKA.     

Two-year fixation and ten-year clinical outcomes of total knee arthroplasty inserted with normal-curing bone cement and slow-curing bone cement: A randomized controlled trial in 54 patients

BackgroundThe normal-curing Refobacin® Bone Cement R (RR) and slow-curing Refobacin® Plus Bone Cement (RP) were introduced after discontinuation of the historically most used bone cement, Refobacin®-Palacos® R, in 2005. The aim of this study was to compare total knee arthroplasty component fixation with the two bone cements.Methods54 patients with primary knee osteoarthritis were randomized to either RR (N = 27) or RP (N = 27) bone cement and followed for two years with radiostereometric analysis of tibial and femoral component migration and dual-energy x-ray absorptiometry measured periprosthetic bone mineral density (BMD). Further, patients were followed up at ten years with clinical outcome scores (OKS and KOOS).ResultsAt two-years follow-up, tibial total translation was 0.31 mm (95% CI: 0.19 – 0.42) for the RP group and 0.56 mm (95% CI: 0.45 – 0.67) (p < 0.01) for the RR group. There was continuous tibial component migration from one to two years follow-up (MTPM > 0.2 mm) in 13/27 patients from the RR and in 12/26 patients from the RP group. There was no difference between groups in BMD baseline values or changes during follow-up, as well as no correlation between change in BMD and tibial component migration. At ten-years follow-up, the improvement in the clinical outcome scores was similar between groups. There were no prosthesis related complications during the 10-year follow-up.ConclusionAt two years, tibial total translation was lower in the RP compared with the RR cement group, but BMD changes were similar. At ten years, no components were revised and clinical outcome scores were similar between groups.     

The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty

OBJECTIVE:

To evaluate the association between tourniquet and total operative time during total knee arthroplasty and the occurrence of deep vein thrombosis.

METHODS:

Seventy-eight consecutive patients from our institution underwent cemented total knee arthroplasty for degenerative knee disorders. The pneumatic tourniquet time and total operative time were recorded in minutes. Four categories were established for total tourniquet time: <60, 61 to 90, 91 to 120, and >120 minutes. Three categories were defined for operative time: <120, 121 to 150, and >150 minutes. Between 7 and 12 days after surgery, the patients underwent ascending venography to evaluate the presence of distal or proximal deep vein thrombosis. We evaluated the association between the tourniquet time and total operative time and the occurrence of deep vein thrombosis after total knee arthroplasty.

RESULTS:

In total, 33 cases (42.3%) were positive for deep vein thrombosis; 13 (16.7%) cases involved the proximal type. We found no statistically significant difference in tourniquet time or operative time between patients with or without deep vein thrombosis. We did observe a higher frequency of proximal deep vein thrombosis in patients who underwent surgery lasting longer than 120 minutes. The mean total operative time was also higher in patients with proximal deep vein thrombosis. The tourniquet time did not significantly differ in these patients.

CONCLUSION:

We concluded that surgery lasting longer than 120 minutes increases the risk of proximal deep vein thrombosis.     

Sub-vastus approach is more effective than a medial parapatellar approach in primary total knee arthroplasty: A randomized controlled trial

In a prospective single-centre longitudinal randomized controlled trial 116 patients were allocated to the sub-vastus approach, and 115 to the medial parapatellar approach. At one week follow-up, compared to baseline, range of motion, Knee Society (KS) global, KS knee, and KS pain scores were significantly better in the sub-vastus group. At the one year follow-up, WOMAC global and pain scores, SF36 physical function and role-physical scores, and EuroQol utility and pain score were significantly better in the sub-vastus group. The ease of exposure in the sub-vastus approach was significantly worse. There was no significant difference in length of stay or analgesia intake. The sub-vastus approach to total knee arthroplasty was more effective than a medial parapatellar approach at both one week and one year post-operatively, but surgeons reported a less easy exposure in the sub-vastus group.     

Patellar reshaping versus resurfacing in total knee arthroplasty - Results of a randomized prospective trial at a minimum of 7 years' follow-up

ObjectiveTo compare the results of primary total knee arthroplasty with patellar reshaping or resurfacing.MethodsOne hundred thirty-three patients were randomized into patellar reshaping group and patellar resurfacing group. Patellar reshaping includes resecting the partial lateral facet of the patella and the osteophytes surrounding the patella, trimming the patella to match the trochlea of the femoral component. The minimum follow-up time was 7 years. The outcome was measured by anterior knee pain rate, Knee Society clinical score, and radiographs.ResultsEight patients in the reshaping group (12.5%) and 10 patients in the resurfacing group (14.7%) complained of anterior knee pain (P = 0.712). Meanwhile, there were no significant differences between the two groups in terms of total Knee Society score, Knee Society pain score, Knee Society function score, as well as anterior knee pain rate.ConclusionsWith the numbers available, there was no significant difference between the groups treated with patellar reshaping or patellar resurfacing with regard to the KSS, anterior knee pain rate and radiographs. We prefer reshaping the patella to resurfacing the patella because the former preserves sufficient patellar bone stock and can easily be converted to patellar replacement if patients complain of recurrent anterior knee pain.     

Midterm comparison of posterior cruciate-retaining versus -substituting total knee arthroplasty using the Genesis II prosthesis. A multicenter prospective randomized clinical trial

The purpose of the current study was to compare midterm outcomes of posterior cruciate-retaining (CR) versus posterior cruciate-substituting (PS) procedures using the Genesis II total knee arthroplasty (TKA) system (Smith and Nephew, Memphis, TN). Ninety-nine (99) CR and 93 PS TKA's were analyzed in this prospective, randomized clinical trial. Surgeries were performed at seven medical centers by participating surgeons. Clinical outcomes (Knee Society Score, Range of Motion, WOMAC, SF-12, and Radiographic Findings), in addition to postoperative complications, were evaluated with a minimum follow-up of 5 years. Following data analysis, there were no significant differences in patient demographics or preoperative clinical measures between the two groups. At the latest follow-up interval, no significant differences were found between the CR and PS groups with regards to functional assessment, patient satisfaction, or postoperative complication. However, the PS group did display statistically significant improvements in range of motion when compared with the CR group. The results of this investigation would suggest that, while comparable in regards to supporting good clinical outcomes, the PS Genesis II design does appear to support significantly improved postoperative range of motion when compared with the CR design.     

Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomised controlled trial of 29 patients

INTRODUCTION: Extensive blood loss related to knee arthroplasty is quite normal and many patients require blood transfusions. Surgery and the use of pneumatic tourniquets lead to an increase in the activity of the fibrinolytic system, which in turn may accentuate the blood loss. Drugs that inhibit the fibrinolytic system may thus be used to reduce blood loss. Tranexamic acid (TA) acts by binding to one of the enzymes at the start of the coagulation cascade, so inhibiting the fibrinolytic system. A concern is that this inhibition may have the side effect of increasing thromboembolic disease, a common complication of joint replacement surgery. We aimed to confirm the reductions in blood loss and to assess the impact of TA usage on clinical and sub-clinical DVT. METHOD: We performed a prospective, randomised, double blind, controlled trial, using patients due to undergo primary unilateral total knee arthroplasty. Patients were randomised to receive either 15 mg/kg of tranexamic acid or a similar volume of normal saline at the time of cementing of the prosthesis. Perioperative blood loss was recorded and patients were screened for DVT with duplex ultrasound assessment of both legs on the fifth post-operative day. RESULTS: A statistically significant (p=0.006) decrease in blood loss in the early post-operative period was noted in the group receiving tranexamic acid. This was not associated with a significant difference in total blood loss (p=0.55) or in transfusion requirements. There was no of evidence in DVT in either group on duplex ultrasound screening of the lower limbs. INTERPRETATION: One injection of 15 mg/kg of tranexamic given at the time of cementing the prosthesis in total knee arthroplasty, before deflation of the tourniquet, significantly decreases the amount of blood loss in the early post-operative period. The treatment was not associated with an increase in thromboembolic complications.     

Evaluation of different coatings of the tibial tray in uncemented total knee arthroplasty. A randomized controlled trial with 5 years follow-up with RSA and DEXA

BackgroundRegenerex® is a porous titanium construct with a 3D interconnecting pore structure and biomechanical characteristics close to that of normal trabecular bone. This study aimed to compare the Regenerex (VR) to the non-interconnecting pore structure Porous Plasma Spray (VP) on tibial implants for total knee arthroplasty (TKA) at 5 years.MethodsWe enrolled and randomized 61 patients (mean age = 63(49–71) years, Female/Male = 35/26) who were planned for an uncemented Vanguard TKA (Biomet, Warsaw, Indiana, USA) to receive either a VR or a VP coated tibial component (31/29). We performed radiostereometric analysis (RSA) and Dual Energy X-ray Absorptiometry (DEXA) postoperatively, and at three, six, 12, 24 and 60 months with measurements of migration. In total 55 patients attended the 5-year follow-up.ResultsOne patient died and four were reoperated during the 60-months period; none due to aseptic loosening. All reoperations were in the VR-group. The mean (range) 60-months MTPM was 1.4 mm (0.5–3.7) for the VP-group and 1.8 mm (0.4–4.9) for the VR-group (p = 0.8). The 24 to 60-months mean (range) MTPM was −0.3 mm (−5 to 1.24) in the VP-group and 0.2 mm (−0.4 to 3.5) in the VR-group (p = 0.8).ConclusionWe did not find any statistically significant differences between the VP- and VR-group and both groups show recognizable migration. We will continue to follow the groups for years to come.     

Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial

BackgroundUltrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB.MethodsSeventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay.ResultsThere was no difference in pain score during movement between the groups (mean difference −0.48 [−1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay.ConclusionsThe SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.     

The effect on wear of lift-off in total knee arthroplasty

Femoral lift-off has been reported in total knee arthroplasty using dynamic fluoroscopic analysis. However, the effect of femoral lift-off on ultra-high-molecular-weight polyethylene (UHMWPE) is not clear. The objective of this study was to evaluate the effect of lift-off movement on the wear of UHMWPE using a pin-on-disc testing machine. Using oxidised UHMWPE, delamination was observed in 70% of the discs with lift-off movement, as against none in without lift-off movement (p=0.0603). In non-oxidised UHMWPE the depth of the wear track was increased in the impact area after lift-off, but there was no delamination and no increase in wear as measured by weight loss. UHMWPE can sustain the impact of after lift-off with neither delamination nor wear by other mechanisms. In contrast, degraded (i.e., oxidised) UHMWPE undergoes delamination after lift-off. Since it is probable that lift-off cannot be prevented, oxidised UHMWPE should never be used in TKA.