Tourniquet use for knee replacement surgery
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Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. A tourniquet may be associated with increased risk of pain and complications. To determine the benefits and harms of tourniquet use in knee replacement surgery a study was conducted.

Researchers included randomised controlled trials (RCTs) comparing knee replacement with use of a tourniquet versus without use of a tourniquet and non-randomised studies with more than 1000 participants. Major outcomes included pain, function, global assessment of success, health-related quality of life, serious adverse events (including venous thromboembolism, infection, re-operation, and mortality), cognitive function, and survival of the implant. Minor outcomes included blood loss, economic outcomes, implant stability, and adverse events.

41 RCTs with 2819 participants were included. Trials included from 20 to 199 participants. Mean age ranged between 58 and 84 years. More than half of the RCTs had unclear risk of selection bias and unclear risk of performance and detection bias due to absence of blinding of participants and surgeons.

Major outcomes were:
Pain: Knee replacement with a tourniquet probably led to higher postoperative pain scores at day 1, although this difference may or may not be noticeable to patients (based on a minimal clinically important difference (MCID) of 1.0).

Function: At 12 months, tourniquet use probably makes little or no difference to function, based on an MCID of 5.3 for Knee Society Score (KSS) and 5.0 for Oxford Knee Score (OKS).

Global assessment of success: At six months, 47 of 50 reported overall successful treatment after surgery without a tourniquet and 47 of 50 with a tourniquet.

Health related quality of life: at six months, tourniquet may have little or no effect on quality of life.

Serious adverse events: the risk of serious adverse events was probably higher with tourniquet; 26 of 898 reported events following surgery without a tourniquet compared to 53 of 901 with a tourniquet. 29 more per 1000 patients had a serious adverse event with a tourniquet.

Survival of implant: It is uncertain if tourniquet has an effect on implant survival due to very low certainty evidence 2 of 107 required revision surgery in the surgery with a tourniquet group compared to 1 of 107 without a tourniquet group at up to two years follow-up.

Moderate certainty evidence shows that knee replacement surgery with a tourniquet is probably associated with an increased risk of serious adverse events. Surgery with a tourniquet is also probably associated with higher postoperative pain. Surgery with a tourniquet does not appear to confer any clinically meaningful benefit on function, treatment success or quality of life.

If a tourniquet continues to be used in knee replacement surgery, patients should be informed about the potential increased risk of serious adverse events and postoperative pain.