A Study on the Use of Tourniquet Use In Primary Total Knee Arthroplasty
A Study on the Use of Tourniquet Use In Primary Total Knee Arthroplasty
A tourniquet is often used in total knee arthroplasty (TKA) to achieve better visualization,
 reduce intra-operative bleeding and facilitate cement interdigitation. On the other hand, the
 associated risks include skin burns, soft tissue and muscle damage, injury of calcified
 vessels, increased swelling and stiffness of the joints, nerve injury, paralysis, and
 thromboembolic events. The automatic lower limb pneumatic tourniquet system (Zimmer) was
 applied to reduce blood loss during surgery. A prospective randomized controlled trial (RCT)
 was performed to investigate the best tourniquet strategy in TKA. The participants were
 randomly allocated to groups with different tourniquet strategies: Group 1) tourniquet
 inflation from skin to cement hardening (skin to cement); Group 2) tourniquet inflation only
 from cementation (cement only) and Group 3) tourniquet inflation from skin incision to skin
 closure (skin to skin). In addition to the blood loss and early postoperative outcomes, pain,
 soft tissue injury, and rehabilitation were also strictly monitored with a longer follow-up
 duration up to 6 months.
A tourniquet is often used in total knee arthroplasty (TKA) to achieve better visualization,
 reduce intra-operative bleeding and facilitate cement interdigitation. On the other hand, the
 associated risks include skin burns, soft tissue and muscle damage, injury of calcified
 vessels, increased swelling and stiffness of the joints, nerve injury, paralysis, and
 thromboembolic events.

 The automatic lower limb pneumatic tourniquet system (Zimmer) was applied to reduce blood
 loss during surgery. The skin under the tourniquet was covered by cast padding. The operated
 leg was elevated and exsanguinated before inﬂating the automatic pneumatic tourniquet. There
 are three main strategies for the use of a tourniquet in TKR: A) inflate before incision and
 deflate following cement hardening ('skin to cement'); B) inflate prior to cement application
 and deflated following hardening ('cement only'); C) inflate before incision and deflate
 following completion of skin closure ('skin to skin'). The optimal timing of tourniquet
 application during primary TKA is still a matter of debate. Most previous reports have failed
 to show signiﬁcant differences among different tourniquet strategies.

 Kvederas et al. compared these three strategies in a randomized double-blind clinical trial,
 and demonstrated that the estimated blood loss was highest when the tourniquet was inﬂated
 just before cement application and deﬂated after its hardening ('cement only'), while
 inﬂation of tourniquet before skin incision and its deﬂation after hardening of cement ('skin
 to cement') tends to give better early postoperative mobilization. However, this was an
 interim report with limited number of patients, and only limited outcome parameters were
 reported, which were insufﬁcient to draw ﬁrm conclusions regarding the differences in
 outcome.

 Therefore we performed this prospective randomized controlled trial (RCT) with a decent
 sample size to investigate the best tourniquet strategy in TKA. In addition to the blood loss
 and early postoperative outcomes, we also strictly monitored pain, soft tissue injury, and
 rehabilitation with a longer follow-up duration up to 6 months.

 All of the operations were performed through the medial parapatellar approach by the same
 experienced joint replacement surgeon. All patients underwent primary TKA with minimally
 invasive techniques and cemented prostheses (EvolutionTM medial pivot, MicroPort, USA). An
 intramedullary guide was used for both tibial and femoral cuts.

 The automatic lower limb pneumatic tourniquet system was applied to reduce blood loss during
 surgery. The skin under the tourniquet was covered by cast padding. The operated leg was
 elevated and exsanguinated before inﬂating the automatic pneumatic tourniquet. One of the
 three tourniquet treatment strategies was used, as determined by the group allocation of the
 patient. In all the three groups, the tourniquet was inﬂated to a pressure of 280 mm Hg. The
 wound was closed after wound irrigation and hemostasis and then was wrapped with elastic
 bandages. One drainage was applied postoperatively in all patients and was kept until 24h to
 monitor blood loss.
Inclusion Criteria:

 1. Patients suffer from primary osteoarthritis indicated for total knee arthroplasty

 2. Subject is physically and mentally willing and able to comply with the postoperative
 scheduled clinical and radiographic evaluations

 3. Subject must have signed an informed consent document specific to the study, and
 approved by the Ethics Committee, indicating that they understand the purpose of and
 procedures required for the study and are willing to participate in the study

 Exclusion Criteria:

 1. Subject requires a revision knee arthroplasty surgery

 2. Subject is currently on anti-coagulant therapy or has coagulopathy

 3. Subject has peripheral vascular disease of the lower limb evidenced by the presence of
 blood vessel calcification on the radiographs or the absence of dorsalis
 pedis/popliteal pulses

 4. Subject suffers from conditions other than primary knee osteoarthritis, e.g.
 inflammatory arthritis

 5. Subject having associated medical diseases affecting rehabilitation

 6. Subject has active systemic infection or infection near the knee joint

 7. Subject having current medical condition that render them unfit for surgery

 8. Any criterion which in the opinion of the investigator, suggests that the subject
 would not be compliant with the study protocol