Tourniquet-less Revision TKA a Viable Option for Selected Patients
Key findings
- This matched-cohort retrospective study compared 274 patients who underwent revision total knee arthroplasty (TKA) with a tourniquet and 274 patients who had the tourniquet omitted
- Tourniquet-less revision TKA led to increased perioperative blood loss (1,549 mL vs. 1,418 mL in the tourniquet cohort; P<0.001), but there was no significant difference between cohorts in perioperative transfusion rate
- Tourniquet use was associated with higher odds of unplanned readmission within 30 days of discharge (OR, 1.88; P=0.04) or a major complication within 90 days (OR, 1.65; P=0.039)
- Tourniquet-less revision TKA was also associated with reduced length of hospital stay and increased range of flexion 90 days after discharge; operative time and rates of minor complications were comparable to outcomes with tourniquet use
Tourniquet use during primary total knee arthroplasty (TKA) has demonstrated benefits on patient outcomes, but its effect in revision TKA is largely undocumented.
Subscribe to the latest updates from Orthopaedics Advances in Motion
In a propensity matched-cohort retrospective study, Massachusetts General Hospital's Venkatsaiakhil Tirumala, MS, of the Bioengineering Laboratory, Anand Padmanabha, MD, arthroplasty fellow, Young-Min Kwon, MD, PhD, director of the laboratory and vice-chair of clinical research in the Department of Orthopaedic Surgery, and colleagues found that, although omitting a tourniquet during revision TKA was associated with increased perioperative blood loss, there was no significant increase in transfusion rate.
Furthermore, as they report in the Journal of the American Academy of Orthopaedic Surgeons, tourniquet-less revision TKA was associated with reduced hospital stay lengths, 30-day readmission rates and overall 90-day major complications, as well as increased range of flexion 90 days after discharge.
Methods
A tourniquet is routinely used in total knee arthroplasty (TKA) to limit perioperative blood loss and increase the surgeon's clear field of view. However, there is a paucity of data on the postoperative clinical outcomes and complications associated with tourniquet use in revision TKA.
The researchers retrospectively identified 1,474 consecutive patients who underwent revision TKA and were followed for at least two years or until re-revision surgery. Of these, 77% had tourniquet-assisted TKA, and 23% did not.
As these two cohorts weren't randomized, propensity score-based matching was done to adjust for baseline differences in patient demographics and procedure details for the two groups. This matching resulted in each cohort having 274 patients (548 total) who were similar in age, sex, BMI, laterality of implant, revision indication, implant types, follow-up time, American Society of Anesthesiologists score, Charlson comorbidity index, race, comorbidities and preoperative inflammatory markers.
Perioperative Outcomes
Compared to patients who underwent TKA with tourniquets, tourniquet-less patients had:
- Comparable procedure durations
- More intraoperative blood loss (mean 414 vs. 353 mL; P<0.001) and more total perioperative blood loss (1,549 vs. 1,418 mL; P<0.001)
- Comparable need for intraoperative transfusions and total perioperative transfusions
- Shorter postoperative hospital stays (3.2 vs. 3.7 days; P<0.001)
Longer-term Outcomes
After discharge, patients who underwent tourniquet-less revision had:
- A significantly lower rate of major complications within 90 days than those who had a tourniquet (11.7% vs. 17.9%, OR, 1.65; P=0.039)
- A comparable rate of minor complications within 90 days
- Comparable rates of all individual minor or major complications, including wound dehiscence and venous thromboembolism
- A markedly lower 30-day readmission rate (6.6% vs. 11.7%; OR, 1.88; P=0.04); 60- and 90-day readmission rates were comparable
- A significantly higher range of flexion 90 days after discharge (mean 108.3° vs. 103.6°; P<0.001); flexion was comparable at 1 year
Commentary
In this propensity-matched cohort study, although omitting the tourniquet in revision TKA was associated with increased perioperative blood loss, notable differences in perioperative transfusion rates were not observed. Furthermore, revision TKA without tourniquet use was associated with reduced postoperative length of stay, 30-day readmissions and increased range of flexion.
In the tourniquet cohort, an incremental increase of 12 minutes in tourniquet time after 100 minutes was correlated with 10% higher odds of an adverse postoperative event, including in-hospital and 90-day complications.
It's also noteworthy that patients given a tourniquet demonstrated higher cumulative odds of major complications. Although tourniquet use did not affect a specific major complication, the long duration of tourniquet use required in revision TKA may be associated with increased overall postoperative morbidity.
view original journal article Subscription may be required
Learn more about the Bioengineering Laboratory at Mass General
Refer a patient to the Hip & Knee Service