Influence of the Tourniquet on Pain and Function in Total Knee Arthroplasty: a Systematic Review and Meta-Analysis

Abstract

Background The use of the tourniquet in total knee arthroplasty is still a subject of controversial discussion. Previous studies mainly focus on parameters like blood loss and operation time. The aim of this systematic review is to evaluate the postoperative outcome involving parameters such as pain intensity, analgesic consumption, knee function and complication rate with and without tourniquet use, to find a recommendation for future application in total knee arthroplasty.

Material and Methods This review is based on the PRISMA Checklists. A systematic research was performed in PubMed using the key words “tourniquet”, “total knee arthroplasty”, “TKA” and “knee endoprosthesis” up to and including January 2018. The initial search revealed 686 Papers which were extracted by the parameters intensity of pain, analgesic consumption, function (range of motion, Hospital for Special Surgery Score, Knee Society Score) and complications (deep vein thrombosis, surgical side infection, pulmonary embolism). The program Review Manager Version 5.3 was used for statistical analysis. A significance level of p < 0,05 was defined.

Results 18 studies were included in this review with 1279 total knee arthroplasties overall (646 with the use of tourniquet and 633 without). The analysis shows a significant lower pain intensity until the fifth postoperative day (p = 0,03) and also after one to three months (p = 0,04) without using the tourniquet. Range of motion is significantly higher in two to three days postoperatively (p < 0,00 001) when the surgery was performed without tourniquet. Knee Society Score shows no difference between the two groups. A deep vein thrombosis appears significantly more often when using a tourniquet (p = 0,04). There was no higher occurrence in pulmonary embolism and surgical side infections.

Conclusion The use of a pneumatic tourniquet in total knee arthroplasty affects especially the early postoperative pain and functional recovery.

Key words

tourniquet - total knee arthroplasty - pain - function - complication

Publication History

Article published online:
25 September 2019

• References/Literatur

• 1 Statistisches Bundesamt (Destatis). Die 20 häufigsten Operationen insgesamt (OPS-Schlüssel 5) vollstationär behandelte Patientinnen und Patienten in Krankenhäuser 2017. Im Internet (Stand: 20.11.2018): https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/Tabellen/drg-operationen-insgesamt.html
• 2 Berry DJ, Bozic KJ. Current practice patterns in primary hip and knee arthroplasty among members of the American Association of Hip and Knee Surgeons. J Arthroplasty 2010; 25: 2-4 doi:10.1016/j.arth.2010.04.033
• 3 Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg Br 1995; 77: 250-253
• 4 Tetro AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg 2001; 44: 33-38
• 5 Fukuda A, Hasegawa M, Kato K. et al. Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg 2007; 127: 671-675 doi:10.1007/s00402-006-0244-0
• 6 Jiang FZ, Zhong HM, Hong YC. et al. Use of a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Sci 2015; 20: 110-123 doi:10.1007/s00776-014-0664-6
• 7 Zhang W, Li N, Chen S. et al. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2014; 9: 13 doi:10.1186/1749-799x-9-13
• 8 Stetzelberger V, Obertacke U, Jawhar A. Tourniquet application during TKA did not affect the accuracy of implant positioning: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2018; 26: 1728-1736 doi:10.1007/s00167-017-4760-y
• 9 Zhou K, Ling T, Wang H. et al. Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. J Orthop Surg Res 2017; 12: 172 doi:10.1186/s13018-017-0683-z
• 10 Ledin H, Aspenberg P, Good L. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthop 2012; 83: 499-503 doi:10.3109/17453674.2012.727078
• 11 Pfitzner T, von Roth P, Voerkelius N. et al. Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24: 96-101 doi:10.1007/s00167-014-3341-6
• 12 Scott CE, Howie CR, MacDonald D. et al. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br 2010; 92: 1253-1258 doi:10.1302/0301-620x.92b9.24394
• 13 Alcelik I, Pollock RD, Sukeik M. et al. A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty 2012; 27: 331-340 doi:10.1016/j.arth.2011.04.046
• 14 Yi S, Tan J, Chen C. et al. The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2014; 134: 1469-1476 doi:10.1007/s00402-014-2056-y
• 15 Li C, Zeng Y, Shen B. et al. A meta-analysis of minimally invasive and conventional medial parapatella approaches for primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23: 1971-1985 doi:10.1007/s00167-014-2837-4
• 16 Tai TW, Lin CJ, Jou IM. et al. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2011; 19: 1121-1130 doi:10.1007/s00167-010-1342-7
• 17 Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee 2010; 17: 141-147 doi:10.1016/j.knee.2009.06.007
• 18 Fillingham YA, Ramkumar DB, Jevsevar DS. et al. The efficacy of tranexamic acid in total knee arthroplasty: a network meta-analysis. J Arthroplasty 2018; 33: 3090-3098.e1 doi:10.1016/j.arth.2018.04.043
• 19 McInnes MDF, Moher D, Thombs BD. et al. Preferred Reporting Items for a Systematic Review and Meta-analysis of diagnostic test accuracy studies: The PRISMA-DTA statement. JAMA 2018; 319: 388-396 doi:10.1001/jama.2017.19163
• 20 da Costa Santos CM, de Mattos Pimenta CA, Nobre MR. The PICO strategy for the research question construction and evidence search. Rev Lat Am Enfermagem 2007; 15: 508-511
• 21 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560 doi:10.1136/bmj.327.7414.557
• 22 Guler O, Mahirogullari M, Isyar M. et al. Comparison of quadriceps muscle volume after unilateral total knee arthroplasty with and without tourniquet use. Knee Surg Sports Traumatol Arthrosc 2016; 24: 2595-2605 doi:10.1007/s00167-015-3872-5
• 23 Liu PL, Li DQ, Zhang YK. et al. Effects of unilateral tourniquet used in patients undergoing simultaneous bilateral total knee arthroplasty. Orthop Surg 2017; 9: 180-185 doi:10.1111/os.12329
• 24 Harvey EJ, Leclerc J, Brooks CE. et al. Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty. J Arthroplasty 1997; 12: 291-296
• 25 Tai TW, Chang CW, Lai KA. et al. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am 2012; 94: 2209-2215 doi:10.2106/jbjs.k.00813
• 26 Li X, Yin L, Chen ZY. et al. The effect of tourniquet use in total knee arthroplasty: grading the evidence through an updated meta-analysis of randomized, controlled trials. Eur J Orthop Surg Traumatol 2014; 24: 973-986 doi:10.1007/s00590-013-1278-y
• 27 Ejaz A, Laursen AC, Kappel A. et al. Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop 2014; 85: 422-426 doi:10.3109/17453674.2014.931197
• 28 Vandenbussche E, Duranthon LD, Couturier M. et al. The effect of tourniquet use in total knee arthroplasty. Int Orthop 2002; 26: 306-309 doi:10.1007/s00264-002-0360-6
• 29 Harsten A, Bandholm T, Kehlet H. et al. Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty; a randomized controlled trial. Knee 2015; 22: 126-130 doi:10.1016/j.knee.2014.12.010
• 30 Wakankar HM, Nicholl JE, Koka R. et al. The tourniquet in total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br 1999; 81: 30-33
• 31 Liu D, Graham D, Gillies K. et al. Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. Knee Surg Relat Res 2014; 26: 207-213 doi:10.5792/ksrr.2014.26.4.207
• 32 Dennis DA, Kittelson AJ, Yang CC. et al. Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res 2016; 474: 69-77 doi:10.1007/s11999-015-4393-8
• 33 Endres S SD, Wilke A. Effects of tourniquet in total knee arthroplasty with regard to functional outcome and complications. OUP 2013;
• 34 Shahi A, Bradbury TL, Guild 3rd GN. et al. What are the incidence and risk factors of in-hospital mortality after venous thromboembolism events in total hip and knee arthroplasty patients?. Arthroplast Today 2018; 4: 343-347 doi:10.1016/j.artd.2018.02.014
• 35 Clarke MT, Longstaff L, Edwards D. et al. Tourniquet-induced wound hypoxia after total knee replacement. J Bone Joint Surg Br 2001; 83: 40-44
• 36 Mori N, Kimura S, Onodera T. et al. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: A prospective, randomized study. Knee 2016; 23: 887-889
• 37 Li B, Wen Y, Wu H. et al. The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop 2009; 33: 1263-1268
• 38 Wauke K, Nagashima M, Kato N. et al. Comparative study between thromboembolism and total knee arthroplasty with or without tourniquet in rheumatoid arthritis patients. Arch Orthop Trauma Surg 2002; 122: 442-446