Personalized tourniquet pressure may be a better choice than uniform tourniquet pressure during total knee arthroplasty: A PRISMA-compliant systematic review and meta-analysis of randomized-controlled trials

Abstract

Background: Pneumatic tourniquets are widely used in total knee arthroplasty (TKA). Some surgeons prefer a uniform tourniquet inflation pressure (UTIP) for all patients; others use personalized tourniquet inflation pressures (PTIP) based on systolic blood pressure and limb occlusion pressure. However, no consensus exists regarding the optimal mode of inflation pressure during TKA. This review aimed to appraise if personalized tourniquet inflation pressures are better than uniform tourniquet inflation.

Methods: The databases (Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang) were searched on March 2021 to systematically identify and screen the literature for randomized controlled trials involving PTIP and UTIP during total knee arthroplasty.

Results: Thirteen randomized controlled trials, involving 1204 TKAs (1201 patients) were included in the systematic review. The meta-analysis identified a trend toward less visual analogue scale (VAS) score at rest with PTIP group at 1 day (P = .002), 2 to 3 days (P = .01), and less VAS score at activity 1 day (P < .0001), 2 to 3 days after the operation (P < .00001), and discharge (P < .0001). No significant difference was found between the groups in terms of VAS score at rest when discharge (P = 1.0). We also found no significant difference in terms of intraoperative blood loss (P = .48), total blood loss (P = .15), lower limb vein thrombosis (P = .42), and thigh bullae (P = .17). However, in the PTIP group, we found a significant higher hospital for special surgery (HSS) score (P = .007), broader knee Range of motion (P = .02), less rate of thigh ecchymosis (P = .00001), and shorter thigh circumference at 1 day (P = .006), 2 to 3 days (P = .0005), and discharge (P = .02).

Conclusion: PTIP provides a similar bloodless surgical field compared with the conventional UTIP. Furthermore, PTIP provides less pain intensity, thigh circumference, rate of thigh ecchymosis, higher hospital for special surgery, and better initial recovery of knee flexion in total knee arthroplasty. Therefore, we recommend using a PTIP method during TKA. More adequately powered and better-designed randomized controlled trials studies with long-term follow-up are required to produce evidence-based guidelines regarding the PTIP method.

Figure 1

The search results and selection procedure. The literature search identified 489 citations. Of these, we removed 330 duplicates. Upon reviewing the titles and abstracts of the 159 remaining articles, we excluded 144 papers according to the inclusion criteria and retrieved the full text of 13 articles. Finally, we identified 1204 TKAs (1201 patients) assessed in 13 randomized controlled trials. TKA = total knee arthroplasty.

Figure 2

The risk of bias summary for RCTs. +: no bias; –: bias; ?: bias unknown. The correct randomization and sufficient allocation concealment were adequately described in 10 studies. The blinding of outcome assessment was described in 13 studies, and the blinding of participants and personnel was described in 3 studies. Each study retained complete outcome data and avoided selective reporting. Other potential biases of all studies cannot be ignored. Therefore, we rated them as having an unclear risk of other bias. As a result, the included studies’ overall quality was considered adequate.

Figure 3

The risk of bias graph. The overall quality of the studies was considered adequate.

Figure 4

Pooled analysis of blood loss between the PTIP group and the UTIP group. Patients in both groups experienced similar intraoperative blood loss (MD = –1.41, 95% CI [–5.36, 2.54], P = .48) and total blood loss (MD = –87.23, 95% CI [–206.86, 32.40], P = .15). CI = confidence interval, MD = mean difference, PTIP = personalized tourniquet inflation pressures, UTIP = uniform tourniquet inflation pressure.

Figure 5

Pooled analysis of VAS between PTIP group and UTIP group. In personalized pressure group, there is a significantly lower VAS at rest 1 day after operation (MD = –1.23, 95% CI [–2.03, –0.44], P = .002), 2 to 3 days after operation (MD = –1.02, 95% CI [–1.8, –0.23], P = .01), and lower VAS at activity 1 day after operation (MD = –0.69, 95% CI [–1.02, –0.37], P < .0001), 2 to 3 days after operation (MD = –1.18, 95% CI [–1.49, –0.87], P < .00001) and discharge (MD = –2.29, 95% CI [–3.33, –1.25], P < .0001). Patients in both groups experienced similar VAS at rest when discharge from hospital (MD = –0.00, 95% CI [–0.74, 0.74], P = 1.0). CI = confidence interval, MD = mean difference, PTIP = personalized tourniquet inflation pressures, UTIP = uniform tourniquet inflation pressure, VAS = visual analogue scale.

Figure 6

Pooled analysis of complication rates between PTIP group and UTIP group. Both groups experienced similar rates of lower limb vein thrombosis (MD = –0.03, 95% CI [–0.1, 0.04], P = .42) and thigh bullae (MD = –0.08, 95% CI [–0.17, 0.02], P = .1). There is a significantly lower rate of thigh ecchymosis (MD = –0.19, 95% CI [–0.24, –0.13], P < .00001) in patients with personalized pressure group. CI = confidence interval, MD = mean difference, PTIP = personalized tourniquet inflation pressures, UTIP = uniform tourniquet inflation pressure.

Figure 7

Pooled analysis of HSS between PTIP group and UTIP group. In personalized pressure group, there is a significantly higher HSS (MD = 1.90, 95% CI [0.51,3.29], P = .007). CI = confidence interval, HSS = hospital for special surgery, MD = mean difference, PTIP = personalized tourniquet inflation pressures, UTIP = uniform tourniquet inflation pressure.

Figure 8

Pooled analysis of ROM between PTIP group and UTIP group. There is significantly better knee ROM (MD = 3.82, 95% CI [0.58, 7.06], P = .02) in patients with personalized pressure group. CI = confidence interval, MD = mean difference, PTIP = personalized tourniquet inflation pressures, ROM = range of motion, UTIP = uniform tourniquet inflation pressure.

Figure 9

Pooled analysis of thigh circumference between PTIP group and UTIP group. Thigh circumference is significantly shorter 1 day after operation (MD = –3.08, 95% CI [–5.28, –0.88], P = .006), 3 days after operation (MD = –3.05, 95% CI [–4.78, –1.32], P = .0005) and 5 days after operation (MD = –0.51, 95% CI [–0.95, –0.07], P = .02) in patients with personalized pressure group. CI = confidence interval, MD = mean difference, PTIP = personalized tourniquet inflation pressures, UTIP = uniform tourniquet inflation pressure.