Comparison of efficacy and safety of different tourniquet applications in total knee arthroplasty: a network meta-analysis of randomized controlled trials

Ziqin Cao; Jia Guo; Qiangxiang Li; Jianhuang Wu; Yajia Li

doi:10.1080/07853890.2021.1991588

Comparison of efficacy and safety of different tourniquet applications in total knee arthroplasty: a network meta-analysis of randomized controlled trials

Ann Med. 2021 Dec;53(1):1816-1826. doi: 10.1080/07853890.2021.1991588.

Authors

Ziqin Cao¹, Jia Guo², Qiangxiang Li^{3

4

5}, Jianhuang Wu^{1

6}, Yajia Li²

Affiliations

¹ Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China.
² Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China.
³ National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
⁴ Ningxia Geriatric Disease Clinical Research Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China.
⁵ National Clinical Research Center for Geriatric Disorders of Xiangya hospital, Central South University (Sub-center of Ningxia), Yinchuan, Ningxia Hui Autonomous Region, China.
⁶ Department of Hunan Institute of Geriatrics, Hunan People's Hospital, Changsha, Hunan, China.

Abstract

Objective: Total knee replacement (TKA) is an effective way to treat teratogenic and disabling knee diseases such as advanced osteoarthritis. Tourniquets are often used in TKA to reduce bleeding and to get a better visualization of the surgical field, while it is related to safety concerns. We did this network meta-analysis to comprehensively compare the efficacy and safety of various tourniquet application strategies.

Method: PubMed, Embase, Cochrane Library, CNKI, and WanFang Database were systematically searched from January 1990 to May 2020. A network meta-analysis with a frequentist framework was done to assess the relative efficacy and safety by comparing seven clinical important endpoints.

Results: 38 eligible studies that assessed 3007 participants who underwent TKA were included in this network meta-analysis. Tourniquet inflation before osteotomy then deflation after wound closure effectively reduce perioperative bleeding (WMD compared with control group -234.66, 95% CI [-409.19 to -60.13]), while shortening the operation time (WMD -8.98, 95%CI [-14.07 to -3.88]) and reducing postoperative complications, including DVT (OR -0.58, 95%CI [-1.19 to 0.03]) and minor wound complications (OR -1.38, 95%CI [-3.00 to 0.25]). No difference was found in the late postoperative knee pain and function outcomes.

Conclusions: Using tourniquets during the entire operation can effectively reduce blood loss, but it also can cause many safety problems, including DVTs, wound oozing, delayed healing, and serious wound complications. Tourniquet inflation before osteotomy then deflation after wound closure effectively can reduce perioperative bleeding while shortening the operation time and reducing postoperative complications, so it could be the ideal tourniquet application strategy in TKA.Key messagesThis is the first study that comprehensively compared different tourniquet application strategies to evaluate their impact on postoperative recovery following TKA, and five clinically important endpoints were assessed in this study: perioperative blood loss, operation time, postoperative pain and function, and complications.We conclude that tourniquet inflation before osteotomy then deflation after wound closure could be the ideal tourniquet application strategy in TKA.

Keywords: Knee replacement; blood loss; network meta-analysis; tourniquet; tourniquet time.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Arthroplasty, Replacement, Knee / adverse effects*
Blood Loss, Surgical / prevention & control*
Humans
Network Meta-Analysis
Pain, Postoperative
Postoperative Complications* / epidemiology
Postoperative Complications* / prevention & control
Randomized Controlled Trials as Topic*
Tourniquets / adverse effects*

Grants and funding

This study was supported by the National Key R&D Program of China (No, 2019YFA0112100), the National Natural Science Foundation of China (No. 81472073), and the Natural Science Foundation of Hunan Province (2019JJ40518).