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

Xie, Jia; Yu, Hao; Wang, Fangyuan; Jing, Juehua; Li, Jun

doi:10.1186/s13018-021-02366-w

Cited by 17 publications

(16 citation statements)

References 34 publications

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“…Rationale: Tourniquets are commonly used during total knee arthroplasty (TKA) to minimize blood loss and to improve visualization during surgery 417 . However, there is still controversy regarding the impact of tourniquets on postoperative pain, functional outcomes and complication rates after surgery [417][418][419][420][421][422] . Specifically, there are concerns that tourniquet use may be associated with an increased risk of VTE post-operatively [417][418][419] .…”

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: 45% (Strong Consensus)mentioning

confidence: 99%

“…However, there is still controversy regarding the impact of tourniquets on postoperative pain, functional outcomes and complication rates after surgery [417][418][419][420][421][422] . Specifically, there are concerns that tourniquet use may be associated with an increased risk of VTE post-operatively [417][418][419] .…”

Section: 45% (Strong Consensus)mentioning

confidence: 99%

Recommendations from the ICM-VTE: Hip & Knee

2022

Journal of Bone and Joint Surgery

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“…High pressure and prolonged obstruction of arterial blood ow induce ischemic changes in the limbs. Moreover, ischemic tissue perfusion after blood circulation resumes can lead to secondary injury, including compartment syndrome and distal neurovascular problems, with the remaining blood possibly causing deep vein thrombosis [5,20]. Ischemic soft tissue damage did not differ between silicone rings and pneumatic tourniquets [21,22].…”

Section: Postoperative Outcomes Of Sterile Silicone Ring Tourniquetmentioning

confidence: 99%

Sterile silicone ring tourniquets in limb surgery : A prospective clinical trial in pediatric patients undergoing orthopedic surgery

Bae

Kim

Aldosari

et al. 2023

Preprint

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Background Sterile silicone ring tourniquets reduce intraoperative bleeding and provide a wide surgical view. Moreover, sterile silicone ring tourniquets reduce the risk of contamination and are more economical than conventional pneumatic tourniquets. The present study describes the perioperative outcomes of sterile silicone ring tourniquet placement in pediatric patients undergoing orthopedic surgery. Methods This study prospectively recruited 27 pediatric patients aged < 18 years who underwent 30 orthopedic surgeries between March and September 2021. Following complete surgical draping, all operations were initiated by placing sterile silicone ring tourniquets. We investigated the demographic and clinical characteristics of these patients, details about the tourniquet used, and intra- and postoperative outcomes of tourniquet placement. Results Thanks to the narrowness of tourniquet bands (< 2 cm) and tourniquet placement at the proximal ends of the extremities, wide surgical fields were achieved, without limiting joint range of motion. Bleeding control was effective. Tourniquets were applied and removed rapidly and safely, regardless of limb circumference. None of the patients experienced postoperative pain, paresthesia, skin problems at the application site, surgical site infections, ischemic problems, or deep vein thrombosis. Conclusions Sterile silicone ring tourniquets effectively reduced intraoperative blood loss and facilitated wide operative fields in pediatric patients with various limb sizes. These tourniquets allow for quick, safe, and effective orthopedic surgery on pediatric patients.

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“…Total knee arthroplasty (TKA) also has a high incidence of POD [ 13 , 14 ]. Using a tourniquet technique may reduce bleeding during the TKA procedure, but the compression of the tourniquet on the artery and vein of the thigh may increase knee swelling and postoperative pain and increase the risk of thrombosis [ 15 , 16 ]. These changes may lead to more complications after surgery.…”

Section: Introductionmentioning

confidence: 99%

Effect of tourniquet technique on postoperative delirium in elderly patients with total knee arthroplasty: a randomized single-blind controlled trial

Wei

Yuan

et al. 2022

BMC Anesthesiol

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Background The tourniquet technique is often used in total knee arthroplasty (TKA). However, its effect on postoperative delirium (POD) in elderly patients undergoing TKA is unknown. Methods This prospective randomized controlled trial assessed the eligibility of 245 elderly patients. A total of 197 patients who met the inclusion criteria were randomly divided into a tourniquet group (n = 98) and a non-tourniquet group (n = 99). The primary outcome was the incidence of POD within 72 h after surgery. The secondary outcome was the quality of rehabilitation, including inflammatory reaction, postoperative pain, hypoproteinemia and anemia. Results Of 245 patients, 184 patients completed this clinical trial, with 92 cases in each group. There were 14 patients (15.22%) with POD in the tourniquet group and 5 patients (5.43%) in the non-tourniquet group (95% CI 1.076 to 9.067, P = 0.029). The changes in white blood cell count (WBC), the proportion of neutrophils (NEUT%), c-reactive protein (CRP), interleukin-6 (IL-6) and middle patellar circumference in the tourniquet group were higher than those in the non-tourniquet group (P < 0.05). The visual analog scale (VAS) at rest and activity in the tourniquet group were higher than those in the non-tourniquet group (F = 170.102, P < 0.001 F = 75.391, P < 0.001). There were 41 (44.57%) patients with hypoproteinemia in the tourniquet group and 26 (28.26%) in the non-tourniquet group (95% CI 1.106 to 3.765, P = 0.022). Conclusion The application of the tourniquet technique in elderly patients with TKA procedures increased the incidence of POD. This may be attributed to the increased inflammatory reaction, severe postoperative pain and hypoproteinemia caused by the tourniquet technique. Trial registration Clinical trial registration number: ChiCTR2100045711. Full date of the first registration: 23/04/2021.

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

Cited by 17 publications

References 34 publications

Recommendations from the ICM-VTE: Hip & Knee

Recommendations from the ICM-VTE: Hip & Knee

Sterile silicone ring tourniquets in limb surgery : A prospective clinical trial in pediatric patients undergoing orthopedic surgery

Effect of tourniquet technique on postoperative delirium in elderly patients with total knee arthroplasty: a randomized single-blind controlled trial

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