Tourniquet Application During Total Knee Arthroplasty Does Not Benefit Perioperative Blood Loss or Transfusion Requirement with the Routine Use of Tranexamic Acid
Background: The use of a tourniquet during total knee arthroplasty (TKA) continues to be a matter of debate. Advantages of tourniquet use include improved visualization, decreased intraoperative and total blood loss, and possibly decreased transfusion requirement. However, the recent widespread adoption of antifibrinolytic therapy with tranexamic acid (TXA), may negate these benefits. The purpose of this study was to evaluate perioperative blood loss and transfusion requirement with two different tourniquet application strategies, and surgery without the use of a tourniquet during routine, primary cemented TKA.
Methods: A retrospective cohort study was performed of 300 patients undergoing TKA at a single institution after the implementation of a routine intravenous TXA administration protocol and consisted of three groups based on tourniquet usage: tourniquet inflation before incision and deflation following cement hardening (TQ), tourniquet inflation prior to cement application and deflation following hardening (Partial TQ), and no tourniquet usage (No TQ). Each group consisted of 100 consecutive patients. Perioperative blood loss, change in hematocrit and transfusion requirement were compared between groups.
Results: Total blood loss (estimated blood loss and drain output) was lowest in the TQ group, however this was only due a slight decrease in intraoperative estimated blood loss. There was no difference in post-operative drain output, or change in hematocrit levels from preoperative values. There were no transfusions in the Partial TQ and No TQ groups, whereas there were 5 transfusions in the TQ group.
Conclusions: In the era of routine TXA administration during TKA, tourniquet usage does not appear to have a benefit in regards to perioperative blood loss or transfusion requirement.
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.
Wauke K, Nagashima M, Kato N, Ogawa R, Yoshino S. Comparative study between thromboembolism and total knee arthroplasty with or without tourniquet in rheumatoid arthritis patients. Arch Orthop Trauma Surg. 2002;122:442-6.
Kato N, Nakanishi K, Yoshino S, Ogawa R. Abnormal echogenic findings detected by transesophageal echocardiography and cardiorespiratory impairment during total knee arthroplasty tourniquet. Anesthesiology. 2002;97:1123-8.
Abdel-Salam A, Eyres, KS. Effects of tourniquet during total knee arthroplasty. A prospective randomized study. J Bone Joint Surg Br. 1995:77:250-3.
Clarke MT, Longstaff L, Edwards D, Rushton N. Tourniquet induced wound hypoxia after total knee replacement. J Bone Joint Surg Br. 2001;83:40-4.
Dennis DA, Kittleson AJ, Yang CC, Miner TM, Kim RH, Stevens-Lapsley JE. Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res. 2016;474(1):69-77.
Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P. A comparison of outcomes with and without a tourniquet in total knee arthroplasty: A systemative review and meta-analysis of the randomized controlled trials. J Arthroplasty. 2012;27:331-40.
Jiang F, Zhong H, Hong Y, Zhao G. Use of a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Sci. 2015;20:110-23.
Parvizi J, Diaz-Ledezma C. Total knee replacement with the use of a tourniquet: more pros than cons. Bone Joint J. 2013;95-B, Supple A:133-4.
Melvin JS, Stryker LS, Sierra RJ. Tranexamic acid in hip and knee arthroplasty. J Am Acad Orthop Surg 2015;23:732-40.
Yang ZG, Chen WP, Wu LD. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: A meta-analysis. J Bone Joint Surg Am. 2012;94:1153-9.
Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: A prospective, randomized, double blind study of 86 patients. J Bone Join Surg Br 1996;78:434-40.
Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br 2001;83:702-5.
Gillette BP, DeSimone LJ, Trousdale RT, Pagnano MW, Sierra RJ. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res. 2013;471:150-4.
Duncan CM, Gillette BP, Jacob AK, Sierra RJ, Sanchez-Sotelo J, Smith HM. Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty. J Arthroplasty. 2015:30:272-276.
Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz NG, Perez-Chrzanowska H, Figueredo-Zalve R. Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. J Bone Joint Surg Am. 2014;96:1937-44.
Aguilera X, Martinez-Zapata MJ, Hinarejos P, Jordan M, Leal J, Gonzalez JC, Monllau JC, Celaya F, Rodriquez-Arias A, Fernandez JA, Pelfort X, Puig-Verdie LI. Topical and intravenous tranexamic acid reduce bloos loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial. Arch Orthop Trauma Surg. 2015:135:1017-25.
Huang ZY, Pei FX, Ma J, Yang J, Zhou ZK, Kang PD, Shen B. Comparison of three different tourniquet application strategies for minimally infasive total knee arthroplasty: a prospective non-randomized clinical trial. Arth Orthop Trauma Surg. 2014;134:561-70.
Tarwala R, Dorr LD, Gilbert PK, Wan Z, Long WT. Tourniquet use during cementation only during total knee arthroplasty: a randomized trial. Clin Orthop Relat Res. 2014;472:169-74.
Ejaz A, Laursen AC, Jakobsen T, Rasmussen S, Nielsen PT, Laursen MB. Absence of a tourniquet does not affect fixation of cemented TKA: a randomized RSA study of 70 patients. J Arthroplasty. 2015;30:2128-32.
Copyright (c) 2016 Tyler Steven Watters, Daniel L Levy, Raymond H Kim, Todd M Miner, Douglas A Dennis, Jason M Jennings
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