Timing Tourniquet Release in Cemented TKA
Should the tourniquet be removed before or after wound closure? The authors attempt to answer this question in a review and meta-analysis that includes 11 randomized controlled trials.
Wei Zhang, An Liu, Dongcai Hu, Yang Tan, Mohammed Al-Aidaros, and Zhijun Pan
The authors have no disclosures relevant to this article.
Editor’s Note: This article is an excerpt of the authors’ review article, Effects of the Timing of Tourniquet Release in Cemented Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Randomized Controlled Trials, published in Journal of Orthopaedic Surgery and Research.
Total knee arthroplasty (TKA) is typically performed with a tourniquet, which is widely accepted to contribute to:
- Reduction in intraoperative blood loss
- Better visualization of the operative field
- Ease of cementing the prosthesis
However, the optimal timing of tourniquet application – which might influence clinical outcomes – is controversial.  The most common tourniquet application strategies in TKA are:
- Tourniquet release before wound closure for hemostasis
- Tourniquet release after wound closure
Both strategies have their pros and cons:
- Tourniquet release before wound closure for hemostasis. Patients managed this way have had less perioperative pain , better functional recovery [2,3], less blood loss , and lower risk of complications , especially with regard to reoperations due to serious vascular injury.  Some researchers have argued that releasing the tourniquet after wound closure could alter patellofemoral tracking, which could result in unnecessary lateral retinacular release and even patellar instability. [6,7]
- Tourniquet release after wound closure. Other authors believe releasing the tourniquet before wound closure is unnecessary. They found similar blood loss, [8-12] risk of complications, [13-15] and functional recovery [8,13] with or without release of the tourniquet before wound closure for hemostasis. Furthermore, the duration of hemostasis would increase surgical time and anesthetic time, [5,15,16] which might increase unnecessary risks and medical costs.
The main reason for using a tourniquet is to achieve superior cementation in TKA. According to registry data from the United Kingdom, Australia, Sweden, and New Zealand, cemented fixation is more common than non-cemented fixation due to lower failure rates.  Several studies, however, have shown differences in clinical outcomes between cemented and non-cemented TKA, including differences in blood loss and rate of complications. [18-21]
To provide clarity and decrease heterogeneity, several randomized controlled trials (RCTs) concerning the optimal timing of tourniquet application have been published. [2,3,5,8,9,14-16,22-24] Consensus, however, has not yet been attained.
One of the issues is that to the best of our knowledge, all previous meta-analyses have included studies on cemented and non-cemented prosthesis, which does not provide clear evidence for clinical practice. We have, therefore, focused our review and meta-analysis on cemented TKA and the effects of tourniquet release before and after wound closure.
We included 11 RCTs in this meta-analysis. [2,3,5,8,9,14-16,22-24] One study was in German and 10 were in English.
The dataset involved 651 patients with 670 knees, of which 332 patients (342 knees) had tourniquet release before wound closure for hemostasis and 319 patients (328 knees) had tourniquet release after wound closure. Five patients (two in early release group, three in late release group) were lost to follow-up .
Baseline demographics (the average age, BMI, gender ratio) between the two groups were comparable. The tourniquet cuff pressure ranged from 220 to 400 mmHg.
Findings and Discussion
The most important finding of the meta-analysis was that there were no significant differences in the hemoglobin drop, overt blood loss, rate of transfusion, and volume of transfusion between tourniquet release before wound closure for hemostasis and tourniquet release after wound closure in TKA. The risks of overall complications and major complications could be decreased due to tourniquet release before wound closure for hemostasis.
The finding regarding hemoglobin drop between the 2 groups agrees with the findings of other studies. [10-12,20,25] The hemoglobin drop, rather than overt blood loss, is one of the most objective clinical outcomes to reflect overall blood loss. The similar rates and volumes of transfusion between the groups also indicate similar overall blood loss between the two groups. Likewise, one of the RCTs in this meta-analysis also showed no significant difference in calculated blood loss (proposed by Gross) between the two groups in cemented TKA. 
In fact, rapid reactive hyperemia and increased fibrinolytic activity occur after tourniquet release, leading to ongoing bleeding from cut cancellous bone and contributing to major perioperative blood loss. [26,27] It has been demonstrated that a local compressive effect is the primary method to control the bleeding. [12,26]
Although there was less intraoperative blood loss when the tourniquet was released after wound closure, the benefit might be counteracted by more postoperative blood loss, for the surgeons were unable to identify and cauterize small bleeding vessels during the operation. 
Tourniquet release after wound closure might result in unnecessary lateral retinacular release; lateral retinacular release was an independent risk factor associated with the rate of transfusion following TKA. 
As for complications, this meta-analysis demonstrated that tourniquet release before wound closure for hemostasis reduced the risks of overall complications and major complications. Results consistent with this finding were reported in several studies. [12,25,29,30]
The prolonged duration of tourniquet use might be a crucial factor for complications, which suggests longer ischemic time for tissues. Tourniquet release after wound closure could cause more excessive inflammation and muscle damage. 
Moreover, several studies have demonstrated an increased rate of complications, including wound drainage and nerve injury, when longer tourniquet times have been used. [31-33] Every additional 10 minutes of tourniquet time has been associated with an increased risk for complications.  Nerve injuries occur with an odds ratio of 2.8 for each 30 minutes of tourniquet time.  Sherman et al also reported that the use of a tourniquet for longer than 40 minutes placed the patient at moderate risk and that tourniquet use longer than 60 minutes placed the patient at high risk of developing a complication.  These studies demonstrate that it is crucial to minimize tourniquet time.
The tourniquet might alter the patellofemoral tracking when it was released after wound closure. This could influence the surgeon’s judgment, leading to the unnecessary performance of a lateral release, which might have a detrimental effect on patellar viability and could increase the incidence of hematomas requiring drainage and wound edge avascularity. [37-39]
Certain examinations, such as the no thumb test, for patellofemoral tracking could be properly performed when the tourniquet was released before wound closure, which would avoid those issues.
Tourniquet release for hemostasis before wound closure would be a practical way to determine if the patient has sustained major vascular damage. In a recent survey, the rate of acute arterial complications was about 0.1% (37 of 39,196 TKAs) between 1989 and 2012.  Although major vascular injury in TKA is very rare, early recognition and expeditious management are critical for successful outcomes. Tourniquet release after wound closure increases the duration of tourniquet and could mask timely recognition of this complication.
With regard to subjective performance and functional recovery, not enough data are available to be combined and analyzed. Only 2 RCTs reported that better subjective performance and earlier functional recovery were observed at early postoperative follow-ups in patients in the early tourniquet release group. [2,3] Another RCT found no difference in the range of motion between the 2 groups at the first postoperative follow-up 2–3 months after TKA. 
Huang et al and others have found that releasing the tourniquet after wound closure increases inflammation and muscle damage. [25,41]
Some researchers have begun to ask whether the limited use of a tourniquet (using a tourniquet only during the cementation) in cemented TKA facilitates function recovery. In Fan et al’s study, patients had decreased limb swelling and knee joint pain when tourniquet use was limited, although more blood loss was detected. 
The current meta-analysis had several strengths. A thorough search of the literature yielded 11 RCTs to be included, 10 of which were judged to have high methodologic quality. All outcomes of this meta-analysis had low heterogeneity (I2 < 50%); therefore, the findings of this study are more reliable than other meta-analyses, which could be proved by sensitivity analysis. It should be noted that previous meta-analyses [4,43] included several non-RCTs, which likely affected the findings of those studies.
In addition, the primary reason for using a tourniquet with TKA is to achieve superior cementation. Consequently, it is not very important to use a tourniquet in a non-cemented TKA compared with a cemented TKA. Unsolidified cement could limit bleeding from cancellous bone by a tamponade effect;  thus, less blood loss would be detected in cemented TKA.
Ranawat et al’s meta-analysis indicated greater functional outcomes, lower revision rates, and less patellofemoral complications among cemented TKAs.  We therefore excluded studies of non-cemented prostheses. To the best of our knowledge, our study was the first meta-analysis concerning cemented TKA alone.
There are also some limitations in this study. Publication bias might exist in this study using Begg’s test (P = 0.024) and Egger’s test (P = 0.005), for the sample size was small. Nevertheless, the potential bias was minimized by comprehensive search and rigorous assessments of methodology. Meanwhile, we included more RCTs concerning cemented TKAs than previous meta-analysis.
Secondly, some confounding factors such as the timing of drain clamping, method of thromboembolic prophylaxis, the type of postoperative compressive dressing, the type of rehabilitation program, and the tourniquet pressure might influence the outcomes. Moreover, the inflating pressure and duration of application of tourniquet were two crucial factors for complications. However, there were not enough data in the included studies to analyze.
Thirdly, postoperative subjective performance and functional recovery were poorly assessed, and the follow-up period was too short.
Hence, to evaluate the advantages and disadvantages of different tourniquet strategies in cemented TKA properly, further well-designed RCTs are required.
Currently available evidence suggests that tourniquet release for hemostasis before wound closure could reduce the risk of overall complications and major complications compared with tourniquet release after wound closure in cemented TKA, although similar blood loss was observed.
Considering the relatively small sample size, short follow-up period, and lack of assessment of postoperative subjective performance and functional recovery, however, the current evidence is not sufficient to indicate that tourniquet release before wound closure is superior to its release after wound closure in cemented TKA.
Wei Zhang, An Liu, and Zhijun Pan are from the Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Dongcai Hu, Yang Tan, Mohammed Al-Aidaros are from the Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, China
Zhang W, Liu A, Hu D, Tan Y, Al-Aidaros, M, Pan Z. Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research 2014, 9:125 doi:10.1186/s13018-014-0125-0. © 2014 Zhang et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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