The Journal of Bone and Joint Surgery (American). 2007;89:699-705.
doi:10.2106/JBJS.F.00497
© 2007 The Journal of Bone and Joint Surgery, Inc.
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Timing of Tourniquet Release in Knee Arthroplasty

Meta-Analysis of Randomized, Controlled Trials

Krishna Reddi Boddu Siva Rama, MRCS1, Sunil Apsingi, MS2, Sharmila Poovali, MD3 and Anand Jetti, MRCOG4

1 Department of Musculoskeletal Surgery, Imperial College, 7 East, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom. E-mail address: r.rama{at}imperial.ac.uk
2 Department of Orthopaedics, Luton and Dunstable Hospital NHS Trust, Lewsey Road, Luton LU4 0DZ, United Kingdom
3 Ipswich Hospital, Heath Road, Ipswich IP4 5PD, United Kingdom
4 Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, Scotland

Investigation performed at Hammersmith Hospitals NHS Trust, London, United Kingdom

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Background: Some surgeons release the tourniquet before closing the wound to secure hemostasis during knee arthroplasty. We examined whether early tourniquet release could reduce the perioperative blood loss and whether not releasing the tourniquet until after wound closure would increase the risk of early postoperative complications.

Methods:We searched electronic databases and reference lists of relevant articles, retrieved all of the published randomized controlled trials designed to address these issues, and performed a meta-analysis.

Results:Eleven studies involving a total of 872 patients and 893 primary knee arthroplasties were analyzed systematically. The studies showed considerable clinical and methodological diversity. Early release of the tourniquet increased the total measured blood loss (weighted mean difference = 228.7 mL; 95% confidence interval = 168.3 to 289.1; p < 0.00001). Early release also increased blood loss as calculated on the basis of the maximum decrease in hemoglobin concentration (weighted mean difference = 320.7 mL; 95% confidence interval = 204.3 to 437.1; p < 0.00001). The rate of reoperations due to postoperative complications was 3.1% (nine of 290) in the group with late tourniquet release compared with 0.3% (one of 290) in the group with early tourniquet release; the risk difference was 3% (95% confidence interval, 0.1% to 5%), which was significant (p = 0.04).

Conclusions: Early tourniquet release for hemostasis increases the blood loss associated with primary knee arthroplasty. However, tourniquet release after wound closure can increase the risk of early postoperative complications requiring another operation. Well-conducted large studies are needed to further explore the risk of early postoperative complications associated with late tourniquet release in knee arthroplasty.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.


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