Clinical Study Of The Tourniquet And Pain Management For Enhanced Recovery After Total Knee Arthroplasty

BackgroundWith years of development,there is no doubt about the positive effects of total knee arthroplasty(TKA)on knee diseases and its perfection.As the concept of enhanced recovery after surgery(ERAS)rises,it is gradually used for perioperative management in total knee arthroplasty in recent years.The management in enhanced recovery after total knee arthroplasty involves all aspects of perioperative treatment.Among them,the optimization of tourniquet use has been discussed for a long time but were not reached.Perioperative pain management is a very important part in enhanced recovery after TKA.It will have an important impact on postoperative rehabilitation of patients after surgery.Multimodal pain management has been accepted widely in the perioperative period of TKA.Multimodal pain management is the combination of different analgesic protocols to get better analgesic effect and reduced adverse reactions.Now the study of single-modal analgesia is well established,but the study of pain programs is still limited.It requires further research to get an optimal results with a combination of varied analgesic protocols.ObjectiveWe tried to achieve the optimal use of tourniquet and multimodal pain management aspects in enhanced recovery after TKA.The aim of the study is to investigate the effects of tourniquet use on enhanced recovery after TKA and to study the effect and safety of multimodal pain management with periarticular infiltration analgesia.Methods1.Between October 2015 and July 2016,30 consecutive patients that were candidates for simultaneous bilateral TKAs in our hospital were enrolled in this prospective randomized self-controlled study.Subjects were randomized to receive a tourniquet assisted TKA on one knee while the contralateral knee received TKA without tourniquet use.Controlled hypotension was applied during bilateral TKAs.In the tourniquet group,the tourniquet was inflated immediately before the incision and deflated after the last suture of the skin;In the no tourniquet group,a tourniquet was not used.Quadriceps strength,pain score of the knee,limb swelling index,knee active range of motion,the operation duration,intraoperative blood loss,the drainage,the occurrence of complications and the radiographic evaluation score of total knee arthroplasty were recorded and compared between groups.2.From December 2015 to October 2016,64 consecutive patients that were candidates for unilateral TKAs in our institution were enrolled in this prospective randomized controlled study.The patients were randomly assigned to the infiltration analgesia group and the non infiltration analgesia group.On the basis of the same multimodal pain treatment,patients receive the periarticular infiltration analgesia in the infiltration analgesia group but not in the non infiltration analgesia group.Pain score of the knee,pethidine consumption,knee active range of motion,quadriceps strength,the complications,postoperative length of stay,HSS score and SF-36 score were observed and compared between groups.Results1.The no tourniquet group had significantly less pain in the early post-operative period compared with the tourniquet group.Quadriceps strength was significantly higher in no tourniquet group compared with the tourniquet group at 3,5 days postoperatively.The no tourniquet group showed less limb swelling after operation,but intraoperative blood loss was more when not using a tourniquet.There was no difference in knee active range of motion,operation duration,the drainage,the rate of complications and the radiographic evaluation score between the two groups.2.At 12 hour and 1 day after surgery,the pain score of knee in the infiltration analgesia group was significantly less than that in the non infiltration analgesia group.And the pethidine consumption was also less in the infiltration analgesia group.The knee active range of motion was significantly better in the infiltration analgesia group than that in the non infiltration analgesia group at postoperative day1 and 3.Compared with the non infiltration analgesia group,the postoperative length of stay was 1 day shorter in the infiltration analgesia group.There was no difference in quadriceps strength,the occurrence of complications,HSS score and SF-36 score between the two groups.Conclusion1.If the conditions of patients allowed and the operative techniques were established,TKA without tourniquet use could alleviate the pain and limb swelling early postoperatively,and facilitate earlier functional recovery.Furthermore,it did not increase the risk of complications and affect the quality of prosthesis fixation.2.The application of periarticular infiltration analgesia on the basis of multiple analgesia can further relieve pain in early postoperative TKA.And it also could accelerate recovery of patients and shorten the postoperative length of stay.In addition,it did not increase the perioperative risk.