Total Knee Arthroplasty with and without Tourniquet: Comparative study

Background The use of tourniquet during complete knee arthroplasty (TKA) improves protection and reduces blood loss intraoperative. Turniquet use, however, may also have a negative impact after TKA on early recovery of muscle strength and lower extremity function. The purpose of this study was to demonstrate the effect of tourniquet use in TKA on surgery length, need for blood transfusion, and amount of postoperative blood drainage by suction drain, incidence of postoperative wound hematoma, postoperative thigh pain, and early mobilization. Methods Seventy Patients are involved in this study and were divided into two groups; Group A (35) patients were treated with TKA with pneumatic thigh tourniquet. Group B (35) patients were treated with TKA without tourniquet. All patients were suffering from severe knee osteoarthritis and they failed to respond to conservative treatment so they are candidates for primary TKA. The two groups are matched related to age and gender. Selection of patients into two groups done randomly with regard of odd number for group A and even number for group B. Results The results showed no signicant difference regarding age, gender, postoperative DVT and wound hematoma between group A (when tourniquet was used) and group B (when tourniquet was not used) although we have 2 patients developed DVT and 3 patients had wound hematoma in group A but these are statistically not signicant. Regarding post-operative VAS for thigh pain was signicantly less in group B and this will result in early mobilization. Also there was signicant difference in duration of surgery between two groups with less time in group A due to bloodless eld of tourniquet while there was signicantly more postoperative drainage amount of blood through the surgical drains in group A and signicantly more amount of blood transfusion perioperatively in group B which explain that tourniquet can reduce the total amount of blood loss in TKA. Conclusion There is signicant effect of tourniquet in TKA on thigh pain postoperatively, which will effect postoperative mobilization and rehabilitation. Also the tourniquet can result in signicant reduction in time of operation, total blood loss and amount of


Abstract
Background The use of tourniquet during complete knee arthroplasty (TKA) improves protection and reduces blood loss intraoperative. Turniquet use, however, may also have a negative impact after TKA on early recovery of muscle strength and lower extremity function. The purpose of this study was to demonstrate the effect of tourniquet use in TKA on surgery length, need for blood transfusion, and amount of postoperative blood drainage by suction drain, incidence of postoperative wound hematoma, postoperative thigh pain, and early mobilization.
Methods Seventy Patients are involved in this study and were divided into two groups; Group A (35) patients were treated with TKA with pneumatic thigh tourniquet. Group B (35) patients were treated with TKA without tourniquet. All patients were suffering from severe knee osteoarthritis and they failed to respond to conservative treatment so they are candidates for primary TKA. The two groups are matched related to age and gender. Selection of patients into two groups done randomly with regard of odd number for group A and even number for group B.
Results The results showed no signi cant difference regarding age, gender, postoperative DVT and wound hematoma between group A (when tourniquet was used) and group B (when tourniquet was not used) although we have 2 patients developed DVT and 3 patients had wound hematoma in group A but these are statistically not signi cant. Regarding post-operative VAS for thigh pain was signi cantly less in group B and this will result in early mobilization. Also there was signi cant difference in duration of surgery between two groups with less time in group A due to bloodless eld of tourniquet while there was signi cantly more postoperative drainage amount of blood through the surgical drains in group A and signi cantly more amount of blood transfusion perioperatively in group B which explain that tourniquet can reduce the total amount of blood loss in TKA.
Conclusion There is signi cant effect of tourniquet in TKA on thigh pain postoperatively, which will effect postoperative mobilization and rehabilitation. Also the tourniquet can result in signi cant reduction in time of operation, total blood loss and amount of blood transfusion.

Background
The recommended treatment for end-stage knee disease is full knee arthroplasty (TKA), and the tourniquet is routinely used in TKA to prevent blood loss [1]. Nevertheless, postoperative recovery and complications of TKA patients can be affected by the latter [2]. A tourniquet's drawback is the morbidity resulting from its use, particularly in neuromuscular injuries that are secondary to ischemia in the neural and muscle tissues and direct damage to the nerve compression. In addition, in the perioperative period, the hemodynamic changes following in ation and de ation can depress cardiac function [3]. The length and demand for proper use of tourniquet remains controversial, and there are no strict guidelines. This de ned a safe limit of (1-3) hours [4]. Using the tourniquet over two hours and pressures on the lower limbs greater than (350) mmHg increases the risk of compression and neuropraxia [5].
Application of a tourniquet during TKA was commonly used to enhance visualization of the operating area, decrease blood loss intraoperative [6,7] and improve the quality of cementation by providing a relatively bloodless operating eld [8]. An evaluation of current practice practices by members of the American Association of Hip and Knee Surgeons showed that 95% of patients without vascular disease who had TKA had their tourniquet management procedures [9]. Many studies found numerous tourniquetrelated drawbacks, including reduced early knee bending [10][11][12], increased coronary and cerebral microembolies, increased occurrence of deep venous thrombosis, increased risk of arterial thrombosis in subjects with preoperative vascular disease, risk of peripheral nerve damage, and tourniquet in ammation of the skin [13].
The purpose of this study was to demonstrate the effect of tourniquet use in TKA on surgery duration, need for blood transfusion, and amount of postoperative blood drainage through suction drain, incidence of postoperative wound hematoma and postoperative thigh pain, and early mobilization and risk of clinical DVT.

Study Design and patients
This study was a single center, prospective, randomized comparative controlled trial. Seventy Patients are involved in this study. This comparative study was started on March 2016 and ended on October 2018. All subjects who ful lled the inclusion criteria were randomly divided into two groups; Group A (35) patients were treated with TKA with pneumatic thigh tourniquet. Group B (35) patients were treated with TKA without tourniquet. All patients were suffering from severe knee osteoarthritis and they failed to respond to conservative treatment so they are candidates for primary TKA. The two groups are matched related to age and gender. Selection of patients into two groups done randomly with regard of odd number for group A and even number for group B. All patients were followed for a period of two weeks until removal of skin sutures for the following parameters: 1. Amount of blood transfusion done at and after surgery. Under general anesthesia or spinal anesthesia, tourniquet used in-group A and not used in-group B. Prophylactic antibiotic was used with induction of anesthesia in all patients. Patients were in supine position with operating knee in exion, midline incision was used in all patients in both groups, preparation of tibia and femur done then cemented prosthesis were inserted with cement then hemostasis secured and suction drain used in both groups and surgical wound closed in layers and dressing done.

Data Analysis
Statistical analysis was carried out using SPSS version 21 for Windows (SPSS, IBM Company, Chicago, USA). Categorical variables were presented as frequencies and percentages. Continuous variables were presented as (Means ± SD). Student t-test was used to compare means between two groups. Paired t-test was used to compare means for paired reading. Pearson's chi square (X2) and Fisher-exact tests were used to nd the association between categorical variables. A p-value of ≤ 0.05 was considered as signi cant. In Figure (1), the mean differences of (VAS score for thigh pain) between two periods of assessments including (1st day post-operative and 2 weeks post-operative) for group A patients. There was signi cant reduction in VAS for thigh pain between these two periods.

Results
Seventy participants (47 women and 23 men) aged 49-84 years were recruited between March 10, 2016 and October 22, 2018. Thirty five patients were randomly allocated to each group.
Table (1) shows the mean differences of study variables including (age, duration of surgery and amount of drain) according to type of operation (Group A and Group B patients). There were signi cant differences between means of duration of surgery and amount of drain between these two groups.  (1) shows the mean differences of (VAS score for thigh pain) between two periods of assessments including (1 st day post-operative and 2 weeks post-operative) for group A patients. There was signi cant reduction in VAS for thigh pain between these two periods. Figure (2) shows the mean differences of (VAS score for thigh pain) between two periods of assessments including (1 st day post-operative and 2 weeks post-operative) for group B patients. There was signi cant reduction in VAS for thigh pain between these two periods.
Table (2) shows the mean differences of (VAS score for thigh pain) between two groups of including (group A and Group B) 1st day postoperatively. There was signi cant reduction in VAS for thigh pain between these two groups.  Table (3) shows the mean differences of (VAS score for thigh pain) between two groups of including (group A and Group B) 2 weeks postoperatively. There was signi cant reduction in VAS for thigh pain between these two groups.

Discussion
In our study, we found no signi cant difference between the two groups regarding age and gender ( Table  1, Table 4) while there was signi cant deference between the two groups regarding duration of surgery with shorter duration in group A because of bloodless eld that was provided by tourniquet (Table 1).
Also there was signi cant difference between two groups regarding postoperative drainage tube (Table 1) with more blood drainage in group A because without tourniquet most of the bleeding vessels can be hemostased and can avoid postoperative bleeding and this can also explain why there was occurrence of wound hematoma in group A but not in group B although it was not signi cant statistically (Table 4).
In our study, we found signi cant difference in VAS of thigh pain between two groups and this explain how the tourniquet can affect the thigh muscle and subsequently thigh pain and this will limit postoperative mobilization and rehabilitation ( Table 2, Table 3) with increased risk of DVT as in our study DVT occurred with group A but not in group B although it was not signi cant statistically (Table 4). We can see also there was signi cant difference in VAS of thigh pain at 1st postoperative day and after two weeks of surgery in both groups ( Figure 1 and Figure 2). When we compare the results of VAS for thigh pain between the two groups in each period of assessment, there was signi cant difference and this explain the effect of tourniquet on thigh muscles and soft tissues and how it will be re ected as postoperative thigh pain ( Table 2 and Table 3). Regarding blood transfusion for those patients, there was signi cant difference in amount of transfused blood between the two groups with more in group B because of bloodless eld provided by tourniquet especially from bone cutting surfaces (Table 4).
Many researchers around the world [14][15][16] demonstrated a predominance of knee arthroplasties using a tourniquet. The pneumatic tourniquet is widely used in knee surgery, offering a bloodless surgical area, enhancing anatomical structure visualization, and the operating time [17].
Present pneumatic tourniquets are designed to minimize the occurrence of abnormalities, and prospective randomized clinical trials showed no signi cant deep-term deleterious effects in extreme surgery [18]. Moreover, tourniquet devices have reported local and systemic complications. Nerve and muscle are the two tissues that are at greatest risk during use of tourniquet [19]. The advantages of tourniquet use include better vision, decreased blood loss intraoperatively and cement xation enhancement [20].
Silver et al. [21] reported that the adverse effects of tourniquet use included reduced early bending of the knee, increased perioperative pain, swelling of the postoperative limbs, complications of the wound and the development of cardiac and cerebral microembolies [22][23]. Some also recorded an increased incidence of deep venous thrombosis, arterial thrombosis in pre-operative vascular disease cases, and peripheral nerve injury [24][25][26]. The tourniquet prevents blood loss intraoperative, but cannot prevent postoperative blood loss or decrease blood loss overall [27,28].
The lost blood may leak into the soft tissue, resulting in swelling of the limbs that would lead to thigh pain, and additional swelling may impede regeneration of patients' early postoperative function and increase tension of the soft tissue [29]. Yoshida et al. [30] and Tai et al. [31] found that endovascular bleeding is reduced with application of tourniquet, but the use of tourniquet has no advantages with respect to postoperative bleeding, total blood loss or transfusion rates. It reported less intraoperative bleeding with use of tourniquet.

Conclusion
There is signi cant effect of tourniquet in TKA on thigh pain postoperatively, which will effect postoperative mobilization and rehabilitation. Also the tourniquet can result in signi cant reduction in time of operation, total blood loss and amount for blood transfusion. The mean differences of VAS score for thigh pain between two periods of assessments for group A patients.