The most significant finding in this research was that the patients who underwent TKA by using the scalpel could achieve better clinical outcomes. In addition, if forgotten artificial joint after TKA was the final goal, the patients who underwent TKA by using the scalpel would acquire better quality of life.
Blood loss is an major problem in the process of TKA, which will cause many related complications. TXA has been suggested as a treatment option to reduce blood loss during TKA. Some studies have indicated that the intravenous use of TXA in the perioperative period has achieved significant effects in reducing blood loss [18, 19]. Similarly, studies have confirmed that topical use of TXA can obtain similar clinical effects as intravenous use of TXA, and the less possibility of complications [20, 21]. In addition, other studies have pointed out that the topical use of the hemostatic agent, such as Floseal® , has achieved significant results in controlling blood loss during TKA [22-25]. In the present study, in order to reduce the related complications caused by blood loss, all of our patients have combined intravenous and topical use of TXA. Most surgeons believed that, like abdominal surgery [26] and spinal surgery [27], electric cautery could reduce blood loss during TKA. In present study, we did not calculate the estimated blood loss by weighing the gauze and calculating the amount of liquid in the suction bottle. Instead, we adopted a method mentioned in the previous article [28], the blood loss was compared between the two groups by comparing haemoglobin, hematocrit before and after surgery. It has known that one unit of blood loss has an effect of 3 % on hematocrit levels and 1 g/dL on hemoglobin. In our research, we found that there was no significant difference in the hemoglobin levels and hematocrit whether using the electric cautery or the scalpel. Perhaps it was related to the tourniquet, tranexamic acid, and hypotensive anesthesia with low mean arterial pressures during surgery. Furthermore, Tammachote et al. [11] believed that the main cause of intraoperative blood loss might be due to osteotomy and femoral medullary hemorrhage during surgery.
Postoperative wound infection is one of the most severe complications after TKA. The causes of infections are diverse, for example, incision hematoma, contaminated incisions, and less stringent aseptic procedures. Although we used broad-spectrum antibiotics to prevent this problem, we had not got satisfactory results. Some studies have pointed out [29-31] that electric cautery may cause delayed wound healing and histological indicate that tissue damage from electric cautery can easily cause tissue damage and increase the infection rate of the incision site. In addition, previous researches have reported that the inflammatory response at the wound affects early functional exercise after joint replacement [32, 33]. And, the damage caused by electric cautery to surrounding tissues may be the main factor leading to the inflammatory response [13, 14]. These findings were consistent with our study that higher wound complications were found by using the electric cautery after TKA. In order to prevent surgical site infection and wound complications, the Centers of Disease Control and Prevention has put forward prevention guidelines [34]. In addition, as an alternative to traditional dressings, negative-pressure wound therapy (NPWT) has been used to effectively treat open wounds in various situations [35,36]. Recently, there is increasing evidence that closed incisional NPWT (ciNPWT) can potentially reduce the risk of surgical site infection, wound complications, reoperation, and decreased length of hospitalization in patients with TKA [37-39]. Although we did not use this kind of ciNPWT in our study, it might be a better choice when we encounter severe wound complications in the future.
The FJS is a newly developed scoring system in recent years, which is often used to measure patients’ ability to forget joint replacement or joint awareness in daily life. Even if the patient’s knee function is improved and no pain is felt, the FJS score will be lower if the patient is “aware of ” the presence of artificial joints in daily life. As a result, minor complaints that are not identified by specific issues (such as “Can you do sports?”) are called “aware” joints, which may reduce the ceiling effect and more sensitively reflect postoperative quality of life [17, 40]. Ozaki et al. believed that FJS is a scoring system that can express “sense of stability” as “awareness” [41]. Morten et al. believed that FJS combines factors such as stiffness, pain, the ability of daily activities, and patients’ expectations to reflect patients’ ability to forget artificial joints in activities, so this scoring system may be the best tool to evaluate the results of TKA [42]. Another study found that when using the FJS scoring system to evaluate the difference in knee awareness of patients who underwent patellofemoral arthroplasty, unicompartmental knee arthroplasty and TKA treatment, they found that patients who underwent different joint arthroplasties had very large differences in the FJS [43]. In the present study, we found higher FJS score by using the scalpel after TKA, and this might mean that the patients had a higher quality of life.
Increased potential smoke plume risk is another risk factor of electric cautery [11, 12]. Surgical smoke exposure may increase the risk of acute or chronic lung diseases such as pneumonia or asthma. One study noted that in Mexico, as a result of exposure to electric cautery smoke, many surgical surgeries developed lump (58%) and sore throat (22%) in the throat [44]. Some studies have also shown that perioperative nurses have twice as many respiratory diseases as asthma, bronchitis, allergies, and sinus infections in the general population [45, 46]. Therefore, for the safety of patients and medical staff, we should pay more attention to the problem of smoke generated by electric cautery during surgery. However, a previous study pointed out that traditional surgeries with the scalpel were more cost-effective than the electric cautery [11]. Therefore, we recommended that using the ordinary scalpel as much as possible when performing primary TKA.
The limitation of this research was that it had a retrospective short-term follow-up design, which has its potential weaknesses. A prospective and long-term research should be performed to confirm these findings.