Does Tourniquet Use in TKA Increase Postoperative Pain? A Systematic Review and Meta-analysis

Abstract

Background Although tourniquets are commonly used during TKA, that practice has long been surrounded by controversy. Quantifying the case for or against tourniquet use in TKA, in terms of patient-reported outcomes such as postoperative pain, is a priority. Questions/purposes The purpose of this study was to meta-analyze the available randomized trials on tourniquet use during TKA to determine whether use of a tourniquet during TKA (either for the entire procedure or some portion of it) is associated with (1) increased postoperative pain; (2) decreased ROM; and (3) longer lengths of hospital stay (LOS) compared with TKAs performed without a tourniquet. Methods We completed a systematic review and metaanalysis using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines to assess the impact of tourniquet use on patients after TKA. We searched the following databases from inception to February 1, 2015, for randomized controlled trials meeting prespecified inclusion criteria: PubMed, Embase, and Cochrane Central Register of Controlled Trials. Postoperative pain was the primary outcome. Secondary outcomes were postoperative ROM and LOS. The initial search yielded 218 studies, of which 14 met the inclusion criteria. For our primary analysis on pain and ROM, a total of eight studies (221 patients in the tourniquet group, 219 patients in the no-tourniquet group) were meta-analyzed. We also performed a subgroup meta-analysis on two studies that used the tourniquet only for a portion of the procedure (from osteotomy until the leg was wrapped with bandages) and defined this as half-course tourniquet use (n = 62 in this analysis). The Jadad scale was used to ascertain methodological quality, which ranged from 3 to 5 with a maximum possible score of 5. Statistical heterogeneity was tested with I 2 and chi-square tests. A fixed-effects (inverse variance) model was used when the effects were homogenous, which was only the case for postoperative pain; the other endpoints had moderate or high levels of heterogeneity. Publication bias was assessed using a funnel plot, and postoperative pain showed no evidence of publication bias, but the endpoint of LOS may have suffered from publication bias or poor methodological quality. We defined the minimum clinically important difference (MCID) in pain as 20 mm on the 100-mm visual analog scale (VAS). Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to clinical use.

Comparison of Postoperative Effects between Medial Pivot Prosthesis and Posterior Stabilized Prosthesis

“…Previous studies on the timing of releasing tourniquets showed that releasing the tourniquet before the wound recovery would cause an increase in total blood loss but decrease the risk of complications 31,32 . In contrast, in a meta‐analysis, the authors found that the mean pain scores of patients treated with tourniquets were significantly higher than those treated without tourniquets, with the mean pain scores of 5.23 ± 1.94 cm and 3.78 ± 1.61 cm, respectively 33 . Similar with this meta‐analysis, our results showed that the higher VAS on the second day after TKA related to the tourniquet duration, the drain tube extubation time, and drain tube diversion ( P = 0.002, P = 0.025 and P = 0.027), which indicated that the tourniquet should be release as early as possible to relieve pain.…”

CORR Insights®: Does Tourniquet Use in TKA Increase Postoperative Pain? A Systematic Review and Meta-analysis

“…While the current study provides compelling evidence that tourniquet use does not compromise muscle or knee function after TKA [1], the patient population that may be at risk for tourniquet-related complications has not been clearly established nor has the potential benefit of tourniquet use on long-term cemented implant fixation. Future studies should assess the relative risk of tourniquet related adverse effects in presumed high-and low-risk patient populations.…”

“…The studies included in the metaanalysis by Deering and colleagues [1] report postoperative pain, ROM, and hospital length of stay. But if tourniquet use improves cement fixation, then long-term studies are needed to determine whether tourniquets have any effect on the durability of cemented implant fixation in TKA.…”

“…The current study by Deering and colleagues [1] compares tourniquet use for the entire procedure with tourniquet use for a portion of the procedure, and with no tourniquet use during TKA. The authors did not identify any clinically relevant differences in pain and functional outcomes between the groups [1], which shows that transient ischemia to soft tissues does not result in clinically relevant impairment in muscle function after surgery.…”

Short-term outcomes of total knee arthroplasty performed with and without a tourniquet

“… Anti-tourniquet Schnettler et al [ 8 ] – Tourniquet use with tranexamic acid leads to more blood loss than tranexamic acid alone. Functional outcomes Pro-tourniquet Goel et al (randomized controlled study) [ 9 ] – Tourniquet use has similar in-hospital functional results compared to no tourniquet McCarthy et al [ 20 ] – No clinically important differences in pain, ROM, and LOS during an in-hospital stay between groups. Anti-tourniquet Huang et al (randomized controlled study) [ 21 ] – No tourniquet and tranexamic acid leads to less pain, less swelling, better ROM, and satisfaction during hospital stay compared to tourniquet use Chen et al (randomized controlled study) [ 22 ] – Half-course tourniquet use leads to less pain and better ROM than full-course tourniquet use.…”