Reinflation After Early Tourniquet Release in Total Knee Arthroplasty

Study Overview
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Brief Summary
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This study is aimed to determine the efficacy and the safety of the tourniquet reinflation after early tourniquet release in total knee arthroplasty, compared to the method of early deflation without reinflation. The investigators hypothesized that the reinflation after early release of the tourniquet would be effective in terms of improved visualization of the surgical field and decreased operation time and blood loss, whereas it would increase tourniquet-related complication due to longer tourniquet-use time.

Detailed Description
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Total knee arthroplasty(TKA) is mostly performed with tourniquet applied, because it allows decreased intraoperative blood loss, better visualization of surgical field and better cement fixation of the implants, compared to the TKA without using tourniquet. However, there remains a controversy about the timing of tourniquet release, so the tourniquet may be unreleased throughout the whole operation time or released early just after cement fixation of the implants, atc. Early tourniquet release is generally aimed to control hidden arterial bleeding which would not be revealed if the tourniquet was unreleased. This method was reported to reduce arterial bleeding and its related complications, but it was also known that increase intraoperative bleeding, incidence of transfusion, and operation time. On the other hand, late tourniquet release, which the tourniquet is unreleased until the wound is closed, is reported to increase tourniquet-use time and related complications owing to longer tourniquet time, although it gives shorter operation time. The investigators have been used a way of reinflation of tourniquet after early release, once the arterial bleeding was controlled sufficiently, to balance the advantages and disadvantages of the early tourniquet release. The investigators were able to control arterial bleeding during the time the tourniquet was released, and the remained procedures were performed conveniently with good visualization of the surgical field after the tourniquet was reinflated again. However, there was no previous studies about the efficacy and the safety of the way of reinflation after early release of the tourniquet in the literature. Therefore, the investigators ask in this study whether the reinflation after early tourniquet release has advantages over the method of early tourniquet release without reinflation, in terms of efficacy and safety.

Official Title
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The Effects of Tourniquet Reinflation After Early Tourniquet Release in Total Knee Arthroplasty

Conditions
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Osteoarthritis, Knee

Intervention / Treatment
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* Procedure: Reinflation after early tourniquet deflation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis of primary osteoarthritis of the knee Scheduled for elective total knee arthroplasty Written signed consent Exclusion Criteria: Revision TKA Diagnosis other than primary osteoarthritis Intra-articular indwelling drainage Refusing participate

Ages Eligible for Study
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Minimum Age: 40 Years
Maximum Age: 90 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Reinflation after early deflation<br>The tourniquet is released after cement implant fixation, and then reinflated, once arterial bleeding was controlled (Reinflation after early tourniquet deflation). | Procedure: Reinflation after early tourniquet deflation<br>* The tourniquet is released after cement implant fixation, and then reinflated, once arterial bleeding was controlled<br>* Other names: Reinflation after early tourniquet release;|
| No Intervention: No reinflation after early deflation<br>The tourniquet is released after cement implant fixation, and remained deflated without reinflation, even after hemostasis. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Operation time | Total time between initial skin incision and wound closure | from skin incision to wound closure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Tourniquet time | Total time of tourniquet-use during the operation which defined from skin incision to the wound closure | total sum of time between inflation and deflation of tourniquet | 
| Difficulty of the operation | Measured by the number of operative field clearance using gauze to make the remained procedure convenient | from skin incision to wound closure | 
| Incidence of transfusion | The incidence of allogenic or autologous (preoperative autologous blood donation) transfusion after surgery due to significant hemoglobin drop within 2weeks after surgery | within 2weeks after surgery | 
| Wound complications | wound complications evaluated on the 2nd and 14th day after surgery, such as ecchymosis, subcutaneous hematoma, hemarthrosis, and oozing | on the 2nd and 14th day after surgery | 
| Thigh complications | Thigh complication due to the tourniquet, such as ecchymosis, skin bullae, and skin necrosis around the area of tourniquet application | within 2 weeks | 
| Venous thromboembolism | symptomatic deep vein thrombosis and pulmonary embolism, detected within 2weeks after surgery | within 2 weeks | 
| Postoperative pain (VAS) | An independent investigator who was blinded to randomization assessed knee and thigh pain level using 0 to 10 visual analog scale (VAS) that ranged from 0 (no pain) to 10 (worst imaginable pain) on the 2nd and 5th day after surgery. | on the 2nd and 5th day after surgery. | 
| More painful site | An independent investigator who was blinded to randomization assessed the more painful site either knee (operation site) or thigh (tourniquet application site) on the 2nd and 5th day after surgery. | on the 2nd and 5th day after surgery | 
| More painful side in SBTKA | An independent investigator who was blinded to randomization assessed the more painful side in patients undergoing simultaneous bilateral TKA (SBTKA), whose each knee will be allocated into experimental and control group, respectively. | on the 2nd and 5th day after surgery. | 
| Amount of drainage | Total amount of subcutaneous indwelled drainage before removal of it. | Until the drainage removal, average of 1 to 2 days after surgery | 
| Hemoglobin drop on the 2nd day after surgery | The hemoglobin drop calculated by subtracting hemoglobin level of postoperative 2nd day from the preoperative value | On the 2nd day after surgery | 
| Hemoglobin drop on the 5th day after surgery | The hemoglobin drop calculated by subtracting hemoglobin level of postoperative 5th day from the preoperative value | On the 5th day after surgery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Osteoarthritis, Knee, Total knee arthroplasty, Tourniquet, Early release, Reinflation