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Meta-Analysis
. 2021 May;103-B(5):830-839.
doi: 10.1302/0301-620X.103B.BJJ-2020-1926.R1. Epub 2021 Mar 8.

Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery

Imran Ahmed  1   2 , Amit Chawla  3 , Martin Underwood  1 , Andrew J Price  4 , Andrew Metcalfe  1   2 , Charles E Hutchinson  5 , Jane Warwick  1 , Kate Seers  5 , Helen Parsons  1 , Peter D H Wall  1   2
Affiliations
Meta-Analysis

Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery

Imran Ahmed et al. Bone Joint J. 2021 May.

Abstract

Aims: Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.

Results: We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87).

Conclusion: TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery. Cite this article: Bone Joint J 2021;103-B(5):830-839.

Keywords: Serious adverse events; Total knee arthroplasty; Tourniquet.

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Figures

Fig. 1
Fig. 1
Preferred Reporting Items for Systematic reviews and Meta-Analysis flow diagram demonstrating the results from the search and reasons for exclusion.
Fig. 2
Fig. 2
Risk of bias with judgements about each item presented as percentages across all included studies.
Fig. 3
Fig. 3
Forest plot demonstrating the number of serious adverse events in the surgery with a tourniquet group compared to the surgery without a tourniquet group. CI, confidence interval. M-H, Mantel-Haenszel method.
Fig. 4
Fig. 4
Forest plot demonstrating the number of venous thromboembolic events in the surgery with a tourniquet group versus the surgery without a tourniquet group. CI, confidence interval. M-H, Mantel-Haenszel Method.
Fig. 5
Fig. 5
Forest plot demonstrating mean pain scores at day one, two and three. Pain scores were on a ten-point visual analogue scale (lower is better). CI, confidence interval; IV, inverse variance method; SD, standard deviation.
Fig. 6
Fig. 6
Forest plot demonstrating the overall blood loss in the surgery with a tourniquet group versus the surgery without a tourniquet group. CI, confidence interval; IV, inverse variance method; SD, standard deviation.
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References

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