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
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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)