CORR Insights®: Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

Clinical Orthopaedics and Related Research®, Jul 2015

Keun Jung Ryu

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CORR Insights®: Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

1 CORR Insights : Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial Keun Jung Ryu 0 Where Are We Now? 0 0 K. J. Ryu MD (&) Division of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine , 50-1 Yonsei Ro, Seodaemun-gu, Seoul 120-752 , Korea - T ourniquet use during TKA [1] offers better visibility, decreases intraoperative bleeding, and helps in cement-bone interdigitation during surgery [4, 10]. Despite these benefits, the development of thromboembolic events like deep This CORR Insights1 is a commentary on the article ‘‘Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial by Dennis and colleagues available at: DOI: 10.1007/ s11999-015-4393-8. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR1 or The Association of Bone and Joint Surgeons1. This CORR Insights1 comment refers to the article available at DOI: 10.1007/s11999-0154393-8. venous thrombosis [2, 13], pulmonary embolism [5], or multiple cerebral and cardiac microemboli [8, 9] all remain a concern when considering tourniquet use. Other complications include increased leg swelling and pain after release [11, 12], tourniquet-induced wound problems [7], peripheral nerve injury [6], or decreased knee ROM [3]. Although there are ongoing debates regarding the pros and cons of tourniquet use, no sufficient investigations have been made on its possible negative effect on the recovery of lower extremity strength and function, which are vital to postsurgical recovery. The current study by Dennis and colleagues adds to our understanding by finding greater postoperative quadriceps strength and lesser pain for patients in the nontourniquet cohort. In contrast, researchers found no differences in hamstring strength, quadriceps voluntary activation, or unilateral balance ability in patients who underwent bilateral simultaneous TKA. Additionally, the study results found more intraoperative blood loss in the nontourniquet group, but no differences in total blood loss or operative time when compared to the group undergoing same-day bilateral TKA. Where Do We Need To Go? The study design (double-blind ran domized controlled study) by Dennis and colleagues increased the level of evidence to support ‘‘limited or no use of tourniquet during the primary TKA.’’ However, more investigation and quantitative information regarding the relationship between tourniquet time and quadriceps strength is needed. A minimum or average duration of tourniquet use should be investigated in order to determine the cause of quadriceps or hamstring weakness. Researchers should also consider investigating the length of time patients will experience tourniquet-induced muscle weakness as well as its CORR Insights effect on intraoperative and perioperative blood loss. Measuring intraoperative and perioperative blood loss remains challenging, because there are no objective methods to calculate blood loss accurately. When we get some of these questions answered, we may be able to arrive at some practical guidelines pertaining to tourniquet use; any such guideline should consider issues related to bilateral surgery (unilateral, simultaneous bilateral, or staged bilateral), safe durations, and absolute/relative indications and contraindications. How Do We Get There? Future studies must employ a more quantitative approach, and, wherever possible, robust experimental designs (including proper randomization). Studies of function should be large enough to evaluate recovery of lower extremity strength and function as a function of varying tourniquet time (or at least to distinguish among no tourniquet use, limited use, half-course use, and full-course use). In addition, longer-term followup is needed to determine the duration of tourniquetrelated complications. In order to evaluate blood loss, more accurate and objective methods are needed. Our current estimations are based on blood on the sponges, swabs, suction drainage, and wound drainage; a number of important functional these approaches suffer from consid- endpoints, is a good step in the direcerable interrater variability. tion of what we need. More Intraoperatively, a standardized proto- studies—enough to populate a proper col for measuring blood loss is needed. meta-analysis, so that we can derive Diluted blood collected in the suction some evidence-based practice guidelibottle during the surger (...truncated)


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Keun Jung Ryu. CORR Insights®: Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial, Clinical Orthopaedics and Related Research®, 2015, pp. 78-80, Volume 474, Issue 1, DOI: 10.1007/s11999-015-4436-1