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Effects of Tourniquet Use on Blood Loss and Soft-Tissue Damage in Total Knee ArthroplastyA Randomized Controlled Trial
Ta-Wei Tai, MD1; Chih-Wei Chang, MD1; Kuo-An Lai, MD1; Chii-Jeng Lin, MD, PhD1; Chyun-Yu Yang, MD1
1 Department of Orthopaedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 183 Sheng-Li Road, 704, Tainan, Taiwan. E-mail address for T.-W. Tai: david0803@gmail.com. E-mail address for C.-Y. Yang: cyyang@mail.ncku.edu.tw
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Investigation performed at the Department of Orthopaedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Dec 19;94(24):2209-2215. doi: 10.2106/JBJS.K.00813
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Abstract

Background: 

Although tourniquets are widely used in total knee arthroplasty, their effectiveness in reducing blood loss and their influence on the postoperative course remain unclear. Tourniquet-related soft-tissue damage is a related concern. We performed a prospective, randomized, controlled trial to clarify the effect of tourniquets in total knee arthroplasty.

Methods: 

Seventy-two patients undergoing total knee arthroplasty were randomly allocated to a tourniquet or non-tourniquet group. Blood loss and changes in C-reactive protein, creatine phosphokinase, and other indicators of soft-tissue damage were monitored preoperatively and postoperatively on Days 1, 2, and 4. Thigh pain, knee pain, limb swelling, rehabilitation progress, and hospital stays were also recorded for comparison.

Results: 

Patients in the tourniquet group showed smaller decreases in hemoglobin (mean and standard deviation, 2.6 ± 0.9 versus 3.7 ± 1.3 g/dL) and hematocrit (7.6% ± 2.8% versus 10.4% ± 4.0%), less calculated blood loss (303 ± 119 versus 423 ± 197 mL), and smaller increases in C-reactive protein (peak value, 175 ± 55 versus 139 ± 75 mg/dL) and creatine phosphokinase (peak value, 214 ± 89 versus 162 ± 104 U/L) compared with those in the non-tourniquet group. There was slightly less postoperative pain in the non-tourniquet group. There were no significant differences between the groups in terms of swelling, rehabilitation progress, or hospital stays.

Conclusions: 

The use of a tourniquet during total knee arthroplasty was effective for reducing blood loss and avoiding excessive postoperative inflammation and muscle damage. The use of a tourniquet was related to slightly more postoperative pain but did not affect postoperative recovery.

Level of Evidence: 

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Ta-Wei Tai, Chyun-Yu Yang
    Posted on June 06, 2013
    Reply to Dr. Banerjee and Dr. Khanuja
    Department of Orthopaedics, National Cheng Kung University Hospital, Collage of Medicine, National Cheng Kung University, Tainan, Taiwan

    We thank Dr. Samik Banerjee and Harpal S. Khanuja for their useful comments about our article. They drew attention to the interpretation of results and mentioned some possible confounding factors. The information is extreme useful not only for judgment of the clinical data but also for designing further studies to investigate the post-operative outcomes. Dr. Banerjee and Dr. Khanuja noted that serum creatine phosphokinase (CPK) and serum C-reactive protein (CRP) are not reliable markers for soft tissue injuries and post-operative inflammation. Serum CPK levels can be affected by a number of factors such as renal function, muscular activity, other sources of trauma including intramuscular injections, use of some kinds of drugs, and electrocautery. The elevated CRP levels seen post-operatively may not directly correlate with the increased inflammation seen with the non-tourniquet group. The similar measurements have been used in the literature to compare the different surgical approach of total knee arthroplasty.(1)

    We totally agree with Dr. Banerjee and Khanuja that there are many confounding factors affecting the results. However, with a properly designed clinical trial, the bias can be minimized. Thus, we conducted a prospective, randomized, patient and observer-blinded controlled trial instead of a series with a low level of evidence. The surgeons, operating room personnel, caregivers, and nursing staff were also asked to provide patients standardized perioperative care to avoid bias.

    We also agree that the results should be interpreted with caution even in a well-designed trial. The results of serum markers for soft tissue damage were uneven in this study, but at least the levels were not higher in the tourniquet group than in the non-tourniquet group. Therefore, we did not emphasize that the non-tourniquet group had more inflammation and soft tissue damage. Instead, we used a more conservative expression in conclusion: the use of a tourniquet during total knee arthroplasty was effective for reducing blood loss and without excessive postoperative inflammation and muscle damage. This conclusion is also clinically relevant because most surgeons agree that the tourniquet facilitates the surgery, but doubt that it has any negative impact.(3)

    More work is certainly needed to draw any meaningful conclusions about the use of tourniquet in total knee arthroplasty.

    References
    1. Niki, Y.; Mochizuki, T.; Momohara, S.; Saito, S.; Toyama, Y.; and Matsumoto, H.: Is minimally invasive surgery in total knee arthroplasty really minimally invasive surgery? J Arthroplasty, 24(4): 499-504, 2009.
    2. Tai, T. W.; Chang, C. W.; Lai, K. A.; Lin, C. J.; and Yang, C. Y.: Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am, 94(24): 2209-15, 2012.
    3. Tai, T. W.; Lin, C. J.; Jou, I. M.; Chang, C. W.; Lai, K. A.; and Yang, C. Y.: Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc, 2010.

    Samik Banerjee; Harpal S. Khanuja
    Posted on January 13, 2013
    Caution on interpretation of results
    Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, 21215

    We read this article with great interest. Tourniquet use during total knee arthroplasty provides a clear operative field with the potential for reduced intra-operative blood loss and has been routine in total knee arthroplasty. However, concerns over complications such as post-operative swelling, nerve palsy, quadriceps muscle weakness, as well as delay in rehabilitation have renewed interest in minimizing or eliminating tourniquet use in total knee arthroplasty.[1-6]

    The authors are to be complimented for conducting a well-designed prospective, randomized controlled trial addressing the issues of post-operative swelling, blood loss, and muscle damage with the use of an intra-operative pneumatic tourniquet. However, we were surprised by the conclusion that tourniquet use “led to significantly reduced muscle damage and the postoperative inflammatory process,” and the author’s beliefs that there was more soft tissue damage in the non-tourniquet group. These conclusions are based on the elevations of serum creatine phosphokinase (CPK) and serum C-reactive protein (CRP) in the non-tourniquet group.

    While we do not dispute the findings of these serum markers, we have concerns over their interpretation. There are a number of reasons why these markers of muscle injury and inflammation may not be reliable. While CPK is a known marker of muscle injury, there are instances where it may not correspond to the amount of tissue damage. Spuriously low serum levels have been documented in a variety of conditions and in hypoxemic environments such as myocardial infarction, sepsis, and multi-organ failure.[7-12] Gunst et al. have reported that serum CPK levels should be interpreted with caution in conditions leading to depletion of glutathione in its reduced state in the extracellular fluid.[13,14] Reduced glutathione, compared to the oxidized state, maintains the activity and protects against degradation of CPK in the biological fluids. A decrease in the concentration of reduced glutathione, and increase in oxidized glutathione, is found in conditions of hypoxia and oxidative stress.[7-13] These conditions exist during tourniquet ischemia and after reperfusion following release of the tourniquet.[13,15,16] Thus, a spuriously low level of serum CPK may be seen in the tourniquet group which does not reflect the true extent of soft-tissue damage.

    In contrast, myoglobin is unaffected by the concentration of glutathione in the extracellular fluid and may be a more reliable marker of muscle damage in conditions of hypoxic oxidative stress.[13] As the authors report, there was no significant difference in the level of myoglobin reported in the two cohorts in this study.

    Serum CPK levels can also be affected by a number of other factors that may explain the increased levels seen in the non-tourniquet group. These include renal function, muscular activity, and other sources of trauma including intramuscular injections and electrocautery.[17-24] Serum CPK levels, apart from having great individual variability, have also been associated with the use of certain anesthetic, hypo-lipidemic and analgesic drugs (e.g. succinylcholine; acetaminophen; statins) well as co-morbidities such as hypothyroidism.[25-28] These potential confounding variables have not been addressed.

    Finally, the authors have also mentioned that “more” electrocautery was used in the non-tourniquet group. The associated soft tissue necrosis from electrocautery has been shown to increase both serum CPK and CRP.[17,18,29,30] The authors have not taken this into consideration when interpreting the results. A prolonged rise in CRP has been noted post-operatively after catheter ablation procedures for atrial fibrillation and following bipolar diathermy use in tonsillectomy.[29,30] Thus, elevated CRP levels seen post-operatively in this report may not directly correlate with increased inflammation seen with the non-tourniquet group.

    The authors do not comment on the standardization of timing of blood draws and blood sample preservation, and these factors may also have an effect on marker measurements[24,31-33].

    In keeping with these concerns, we would caution interpretation of these findings to suggest more soft tissue injury and inflammation in the non-tourniquet group. This may in fact represent poor correlation of the markers and confounding factors that have not been addressed.

    Disclosure: The authors have no conflict of interest.

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