Introduction: There are no guidelines for the use of any particular tourniquet in foot surgery. We undertook this prospective randomised study to assess the efficacy of the S-MART . TM. tourniquet in foot surgery as compared to the pneumatic tourniquet. A literature review confirms this is the first randomised controlled study objectively measuring the outcomes of this tourniquet system. Material and Methods: We included 40 consecutive patients who had foot surgery from May 2006 to August 2006. Informed consent with local medical ethics committee approval was obtained. We excluded patients with history of diabetes mellitus, deep vein thrombosis, fractures, limb circumference more than 40 centimetres and smokers. The ease of application of tourniquet, intraoperative bloodless field and ease of removal was scored on a scale of 1–10. Patients were followed up at 2 weeks. Results: 20 patients were randomised into group one with pneumatic tourniquet (average age 63.36) and 20 patients in group two with S-MART . TM. tourniquet (average age 61.25). The average tourniquet placement time in-group one was 144.36 seconds as compared to 12 seconds ingroup two. The mean ease of application scores was 4.27 in-group one as compared to 1.46 in-group two. Total tourniquet time was more in-group one. Intraoperative haemostasis was rated higher in-group two. Discussion: SMART . TM. tourniquet provides a good intraoperative haemostasis and is easy to apply. This tourniquet helps to exsanguinate; this frees up theatre personnel, saves resources and decreases tourniquet time for surgery. The limitation is it cannot be reinflated and cannot be used in patients with fractures. Conclusion: S-MART tourniquet is a good for foot surgery, provides a good operative field, is easy to apply and saves precious theatre time and resources

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome.

Aim: To analyse the out come of 200 knee arthroscopies with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications.

Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21–81). All patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and was done by same surgeon as day case. Same arthroscopic kit with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visited the consultant or GP for any wound related problem or pain before the usual review at 2 weeks.

Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring intervention. There was no record of any patients reattending the clinic or their GP for pain or bleeding.

Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued.

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome.

Aim: To analyse the out come of 200 knee arthroscopies done with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications.

Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21–81). All patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and were done by same surgeon as day case. Same arthroscopic kit (Dyonics) with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visited the consultant or GP for any wound related problem or pain before the usual review at 2 weeks.

Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring intervention. There was no record of any patients reattending the clinic or their GP for pain or bleeding.

Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued.

About 81,000 total knee replacements are implanted in the United Kingdom annually. Conventionally pneumatic tourniquet and surgical drains have been used in total knee arthroplasty. However, no definite evidence or guidelines exist to support their use. The present study aims to look for any difference in perioperative recovery and complications following use of pneumatic tourniquet and surgical drains in knee replacement surgery. We retrospectively analysed 60 total knee arthroplasties performed by 3 different surgeons at our hospital during January 2007 to June 2010. A sample size of 20 patients in each group was evaluated. Group 1: used tourniquet and drain; Group 2: used tourniquet but no drain; Group 3: didn't use tourniquet but used drain. Data was collected and analysed using statistical means, t-test & analysis of variance. Parameters compared were surgical (anaesthetic) time, mean postoperative haemoglobin at 24 hrs, blood transfusion rate, haematoma formation, wound infection, pain, deep vein thrombosis and infection at discharge. At 6 weeks clinical follow up letters were analysed. Our results reveal that there is no significant difference in duration of surgery in either group. Use of tourniquets didn't improve on surgical time (123–133 minutes). Our Local Hospital Pain Score was used (1 no pain, 2 mild, 3 moderate, 4 severe and 5 worst imaginable pain). No difference at discharge was seen in either group. Similarly no difference was seen in either group with postoperative haematoma formation with one case (5%) in Group 1 and 3 respectively. Although the immediate postoperative haemoglobin (Hb%) was comparable in all 3 groups, Group 3 patients received more blood transfusion compared to other groups based on clinical grounds. About 50 % of Group 3 needed blood transfusion compared to 10% in Group 1 and 5% in Group 2. There was only one proven case of superficial infection at 6 weeks (Group 2) which responded well to antibiotics. There were 4 cases of cellulitis noted at 6 weeks (3 in Group 2 and 1 in Group 3) which responded to oral antibiotics. No deep infection was noted. The mean hospital stay in hospital was 6.5 days in Group 1, 5.5 days in Group 2 and 8 days in Group 3. There was no difference in rate of post-operative deep vein thrombosis (5% in Group 1 and 3). The present study with the use of tourniquet and surgical drain in total knee arthroplasty showed no significant difference in surgical time and incidence of postoperative haematoma, deep vein thrombosis. Pain score at discharge was comparable and so was the infection rate. Patients in Group 2 (used tourniquet but no surgical drain) had least hospital stay (mean 5.5 days) and least blood transfusion rate (5%). Decision to use pneumatic tourniquet & drain still lies with the operating surgeon. We recommend a randomised control study for further evidence

Introduction. Pneumatic tourniquets (PTs) are commonly used in local anaesthetic cases in the upper limb to provide a bloodless operating field. They give excellent efficacy however their limitations have prompted the introduction of a new single-use sterile silicone ring tourniquet (SRT). The evidence of use of the SRT over the standard PT is limited. Aim. To compare the level of perceived pain, and therefore tolerance, of the Silicone Ring and Pneumatic tourniquets when applied to the upper arm and to evaluate whether there was a clear benefit of use of either tourniquet in local anaesthetic procedures of the upper limb. Materials and methods. 30 volunteers, 15 male and 15 female, with a median age of 42 were recruited to compare the two tourniquets. Pain was measured using a VAS pain scale on application and at 1, 5 and 10 minutes. Results. Volunteers experienced significantly more pain on application and at 1 and 5 minutes with the SRT. This difference in pain perceived was most marked upon application. Two volunteers could not tolerate application of the SRT. Three volunteers experienced bruising of the arm and/or forearm following use of the SRT. There was no difference in pain scores at 10 minutes. Conclusion. Due to the severe pain experienced on application of the SRT it would not be suitable for local anaesthetic procedures in the upper limb. In addition the degree of pain may reduce the patients confidence and adversely affect their experience of the procedure. The PT is more suitable for local procedures. However the SRT may have a role in procedures performed under general anaesthetic

For as long as surgeons have been performing total and partial knee arthroplasty, surgeons have debated the efficacy, safety, and requirement of a pneumatic tourniquet. Advocates claim that blood loss is less, visualization is improved, and the cement technique is better with the use of a tourniquet. Others would argue that the use of the tourniquet or limited tourniquet use is safer, does not increase blood loss, and does not compromise visualization and cementing technique. Multiple meta-analyses have been performed that provide very little true evidence of superiority. One such study from Yi et al, concludes that the use of the tourniquet reduces surgical time, intraoperative and total blood loss, but increases postoperative total blood loss. They also conclude that DVT and SSI are “relatively augmented” with use. There may be issues with the timing of tourniquet release in these pooled studies, with others stating that releasing the tourniquet prior to wound closure, supposedly for hemostasis, significantly increases the total and calculated blood loss. Huang et al report that with proper control in the amount of pressure, a debatable topic in and of itself, and shorter duration of inflation, release after closure can reduce blood loss without increased complications. One additional issue is patellar tracking, and the need to lateral release. The tourniquet significantly affects assessment of tracking and the need for lateral release, potentially causing the surgeon to unnecessarily perform a lateral release with the tourniquet inflated. Lastly, research has suggested that using a tourniquet may affect recovery of lower extremity strength and function. Dennis et al compared quadriceps strength and found that use of the tourniquet resulted in “slightly” lower strength postoperatively out to 3 months. The fatal flaw in this study and others is that there is no accepted minimal clinically important difference for quad function, and thus they powered their study to detect a difference of 12 Nm, and the actual difference, while statistically significant, did not even meet their arbitrary power set point. Thus, while strength may be slightly impaired by the use of a tourniquet, it was not different enough to meet their criteria. Additionally, in their study, 64% of the “no-tourniquet” knees actually had a tourniquet used for cementation to “minimise blood at the bone-cement interface and maximise fixation”. Clearly, even these authors are concerned with the results of not using a tourniquet. These authors utilise a pneumatic tourniquet in all cases of primary TKA and release the tourniquet prior to closure to ensure hemostasis and accurately assess patellar tracking. In doing so, we use the methodology of limb occlusion pressure to minimise the pressure to that necessary for ensuring a clear field. Additionally, these authors emphasise the ultimate in surgical efficiency allowing for extremely short tourniquet times, even in the most difficult cases. As an example, in 1300 consecutive obese patients with BMI equal or greater than 35, the average tourniquet time for primary TKA was 49 minutes. These short times, with the minimum pressure allow for the best of both worlds and little to no downside

Background. There are multiple documented advantages of undertaking total knee arthroplasty (TKA) without tourniquet, however, increased rates of blood loss and transfusion are often cited as contraindications to this approach. The aim of this study was to examine the effect of intra-operative TA administration on blood loss and transfusion rates in TKA without pneumatic tourniquet, using Rivaroxaban as thrombo-embolic prophylaxis. Method. 120 patients split into two continuous data sets, (A+B), underwent TKA without application of above knee tourniquet, receiving a post operative dose of oral Rivaroxaban within 8 hours. Group B patients received an intra-operative dose of 1 gram of Tranexamic Acid intravenously before the first cut, whilst those in group A did not. Haemoglobin and haematocrit levels were recorded peri-operatively. A revised Gross formula was used to calculate blood loss. Four patients were excluded from the study for incomplete data. Results. 58 patients (M34F24) in Group A, average age 6, had a mean haemoglobin drop of 33gram/litre, haematocrit drop of 0.097litre/litre (9.7%), with an average calculated blood loss of 1393ml. 58 (M34, F24) patients in group B, average age 67, had a haemoglobin drop of 25.2gram/litre, haemotocrit drop of 0.076litre/litre (7.6%) with an average calculated blood loss of1079ml. Thus Group A patients were seen to sustain significantly more blood loss without TA administration, with a 29.1% larger calculated blood loss, a 25.5% larger drop in haemoglobin and a 27.6% larger fall in haematocrit. Transfusion rate was 5.2% (3 patients) per group. Conclusion. TA was shown to be effective in reducing blood loss in TKA without tourniquet using Rivaroxaban. Transfusion rates of 5.2% across both groups is close to 1/10th of the transfusion rate reported for some major studies of TKA using Rivaroxaban with tourniquet application, and 1/8th of the transfusion rate in studies of TKA with administration of TA and use of tourniquet. Level of Evidence. Level-III. The authors report there are no relevant disclosures to make. Ethical approval was granted for the study

In modern orthopaedics surgery, the pneumatic tourniquet has become an essential tool that paved the way to many of the advances in trauma and orthopaedic surgery. Tourniquet slippage is one of the challenging disadvantages of it use. This study examines the possibility of reducing tourniquet slippage by comparing two different tourniquet application techniques. Twenty two patients were included in the study. Thirteen were males and eight were females. The average age was fifty five years. The patients were randomized into two groups, a controlled, and a modified tourniquet application technique groups. There were eleven patients in the control group and ten in the modified group. A standard tourniquet application technique was used as a control by applying Softband (Orthoband) alone to skin prior to application of tourniquet; this was compared to a modified version where a drape (Steridrape) was used as an interval layer. There was a strong statistical significant difference in tourniquet slippage between the two groups, p< 0.0001 the control group being the better performer. We concluded that steridrape interval makes tourniquet slippage more likely to occur

Introduction. The purpose of this study was to determine the efficacy of a multi-modal blood conservation protocol that involved pre–operative autologous blood donations (2 units) in conjunction with erythropoietin supplementation as well as intra-operative conservation modalities. Methods. A retrospective chart review of 90 patients with simultaneous bilateral total knee arthroplasty done between 2006–2009 by one of the 3 senior authors was performed. Patients donated two units of blood 4 weeks prior to surgery and also received erythropoietin injections (40,000 units: 3 weeks, 2 weeks and 1 week prior to surgery). Intra- operative blood management included use of pneumatic tourniquet, re-infusion drains, local epinephrine injections and fibrin spray. Post-operatively, autologous transfusions were provided based on symptoms. Pre-donation blood levels, peri-operative hemoglobin and hematocrit levels along with transfusion records were assessed. Results. The mean pre-donation hemoglobin was 13.1 g/dL. After 2 units of autologous blood donation and procrit injections, the mean preoperative hemoglobin was 13.0 g/dL. The mean hemoglobin dropped to 9.8 g/dL on postoperative day 3. The mean drop in hemoglobin from preadmission testing was 3.3 g/dl. Overall, 30% patients required autologous blood transfusion and no patients required allogenic transfusion. Conclusion. This multi-modal protocol was effective in not only avoiding allogeneic transfusions following bilateral TKA but also resulted in high blood levels at the time of discharge. This protocol was effective in eliminating allogenic transfusions and maintaining blood levels

Introduction. Total knee arthroplasty [TKA] is a common procedure to relieve painful disability from advanced knee arthritis. However, related blood loss, ranging from 800 to 1200 ml, increase risk and disruption of recovery in anemic patients following TKA. Various methods for blood conservation had been proposed and examined. In the literature, the intra-articular administration of a solution mixing bupivacaine and epinephrine was commonly used after knee surgeries. Therefore, we conducted a retrospective, case controlled review of our primary TKAs to determine the hemostatic efficacy of this regimen following TKAs. Material and Methods. Over a period of 12 months, 135 eligible patients were divided two groups simply according to the intra-articular injection or not: a control group (N=63) and a treatment group (N=72). In the treatment group, a 40 ml vial of 0.5% bupivacaine with epinephrine 1: 200000 was given prior to the deflation of pneumatic tourniquet. No drainage was used in all TKAs. Without recordable drainage, a Gross formula, considering gender and body composition, was used for estimate blood loss following TKAs. In addition, serial changes in hemoglobin as well as the requirement of allogenic transfusion were also compared between groups. Results. The mean calculated blood loss in the treatment group was 650.4 +/− 257.1 ml, compared to 648.8+/− 222.1 ml in the control group (p=0.9). Similar decrease in hemoglobin as well as rates of allogenic transfusion needs were observed between groups.[2.5+/− 0.9 g/dl vs. 2.4+/− 0.8 g/dl; 13.9% vs. 12.7%, respectively]. Discussion and Conclusion. Although local analgesics mixing vasoconstrictive agents seem a logic solution to save blood loss and relieve pain simultaneously, the hypothesis that intra-articular injection of bupivacaine and epinephrine would save blood and even transfusion needs following TKAs is not supported by various bleeding parameters in this study. In addition to temporary benefit in pain relief, this regimen only has little effect on blood conservation. Therefore, new regimen as well as hemostatic means are still required and explored to reduce blood loss following TKAs

UK personnel have been deployed in Afghanistan since 2001 and over this time a wealth of experience in contemporary war surgery has been developed. Of particular note in the latter Herrick operations the injury pattern suffered by personnel is largely blast wounds, primarily from improvised explosive devices. With the development of improved body armour, previously unsurvivable blasts now result in a large number of traumatic amputations, predominantly affecting the lower limb. Faced with this, deployed medical personnel in the Role 3 facility, Camp Bastion, have developed, by a process of evolution, a standard process for timely management of these injuries. We present a documented schema and photographic record of the ‘Bastion’ process of management of traumatic amputation through the resuscitation department, radiology, theatres and post-operatively. In resuscitation the priority is control of catastrophic haemorrhage with exchange of CAT tourniquets to Pneumatic tourniquets. While undergoing a CT, time can be used to complete documentation. In theatre a process of social debridement & wash then sterile prep followed by formal debridement allows rapid management of the amputated limbs. This work provides a record of current best practice that generates maximum efficiency of personnel and time developed over a large number of procedures. This allows reflection both now in relation to continuing Herrick operations and when military medical services are faced with a future conflict and an inevitable change in injury patterns

Haemorrhage is the main cause of preventable death on the modern battlefield. As IEDs in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the CAT tourniquet to control distal haemorrhage following mid thigh application. Aim. To evaluate the efficacy of the CAT windlass tourniquet in comparison to the newer EMT pneumatic tourniquet. Method. Serving soldiers were recruited from a military orthopaedic outpatient clinic. Participants' demographics and blood pressure were recorded and a short medical history obtained to exclude any arteriopathic conditions. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid thigh level and the presence or absence of the popliteal pulse on Doppler was recorded. The process was repeated on the contralateral leg with the CAT now applied by a trained researcher. Finally the EMT tourniquet was self applied to the first leg and popliteal pulse change Doppler recorded again. Results. 40 consecutive patients were invited to participate in the study. 15 declined to participate. 1 was excluded via pre-determined exclusion criteria. A total of 24 participants were recruited. The self applied CAT occluded popliteal flow in only 4 subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in 2 subjects (8.3%). The EMT prevented all popliteal flow in 18 subjects (75%). Discussion. This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid thigh level. The EMT was successful in a significantly larger number of participants

Bloodless field in limb musculoskeletal tumours’ surgery has great value as it facilitates resection and reconstructions without excessive bleeding. 40 large bone or soft tissue tumors located in upper (n=4) and lower limbs (n=36) were resected and reconstructed in bloodless surgical field achieved by a new device, an elastic silicone ring (S-Mart, OHK Medical Device). Proper size of it is chosen between items of different diameter, length and elasticity depending on their measurements and BP. Our goal was safe and sufficient blood pressure for bloodless operation. In tumours, esh-mark and any pressure on the mass results in microscopic spread. We rolled the ring along the limb, starting from digits and exsanguinated the limb raising it above the tumour to avoid crushing it. If tumours extend too proximally to hip and shoulder we cannot use tourniquet because cuffs are wide enough to allow proximal extension of the incision. The elastic ring we used, is too narrow (Φ< 20cm) and proved of utmost importance in large, bleeding growths helping tumour elimination and limb salvaging. The ring was applied from 18–120 minutes created completely bloodless surgical field thus facilitating and speeding up the operation. The time needed for application was shorter than for pneumatic tourniquet (< 10sec). After removing the elastic ring we noticed neither BP drop nor tumour spread or complications of skin and neurovascular elements pressure. Thus we conclude that limb ischaemia achieved with special elastic rings have benefits and may be considered as safe in oncological surgery

We prospectively randomised 104 consecutive patients undergoing primary cemented total knee arthroplasty to receive either a standard suction drain© (Redivac) or autologous transfusion drain® (Bellovac). There were fifty two patients in each group. Randomisation was performed using a software program (Minim) which set to stratify patients based on their age, sex and body mass index (BMI). All procedures were performed under pneumatic tourniquet. Drains were released in recovery room 20 minutes after surgery and were removed 24 hours following surgery. Blood collected in the standard suction drain was discarded but blood collected in the autologous transfusion drains was transfused unwashed to the patient within six hours of collection. 13 patients (25%) in the study group had two or more units of homologous blood transfused in addition to the blood collected postoperatively and re-transfused (Average= 438mls). 12 patients (23%) in the control group had two or more units of homologous blood transfused. No sepsis, transfusion reactions, or coagulopathies were associated with the autologous blood re-transfused in the study group. The use of autologous transfusion system (Bellovac) proved to be safe but failed to reduce the need for postoperative homologous blood transfusion following uncomplicated total knee arthroplasty

Purpose. The traditional use of pneumatic tourniquets and reinfusion drains in total knee replacement (TKR) has recently been challenged and the aim of our study was to compare the outcomes of three different blood management techniques in primary TKR. Methods. We prospectively conducted a study of 87 patients with mean age of 71 (44-91) years old. They were randomised into three groups: Group A: 29 patients without the use of tourniquet and reinfusion drain, Group B: 27 patients without the use of tourniquet and reinfusion drain but application of intraoperative cell salvage system and Group C: 31 patients with the use of tourniquet and reinfusion drain. All groups were well matched and all patients were reassessed at the 2. nd. postoperative day. Results. There was no difference between the postoperative haemoglobin drop (Group A: 3.6 g/dl; Group B: 3.3 g/dl; Group C: 3.2 g/dl) and allogenic blood transfusion rate (Group A: 6.8%; Group B: 7.4%; Group C: 6.4%). In Group B an average of 525 ml of blood was collected and an average of 148 ml of concentrated blood was reinfused. In Group C an average of 432 ml of blood was collected by the drain and an average of 324 ml of blood was reinfused. The 2. nd. postoperative day range of knee movements showed no significant difference. Only 2 Group C patients (6.4%) had postoperative thrombembolic events (one DVT, one TIA). Readmission rate due to knee stiffness and superficial wound problems did not revealed any significant difference. The average operative time (83 minutes) and hospital stay (5.3 days) were the same in all groups and there was no wound haematoma or deep infection in any groups. Conclusion. There was no statistical difference between the groups for any outcome measure

Introduction: Tourniquets are commonly employed in surgical procedures of the knee. The use of the same tourniquet on a repetitive basis without a standard protocol for cleaning has recently been questioned as a potential source of cross-infection. This study examines the contamination of the tourniquets in our institution and results of cleaning the tourniquets with a disinfectant and detergent wipe. Material and methods: Tryptone soya agar plates were used to take samples from 20 tourniquets employed in knee replacement. Four specified sites on each tourniquet were cultured and incubated at 37° for 48 hrs. Results: All sampled tourniquets were contaminated with colony counts varying from 9 to > 385. Coagulase negative Staphylococcus was the most commonly grown organism from the tourniquets (96%). Some tourniquets had growths of important pathogens including MRSA, Pseudomonas and Staphylococcus aureus (these organisms have not been previously cultured from tourniquets). On cleaning five tourniquets with clinell (detergent and disinfectant) wipes, there was a 99.2% reduction in contamination of the tourniquets five minutes after cleaning. Conclusion: Contamination is more worrying in relation to pneumatic tourniquets, as they are commonly employed in knee surgery where implants are frequently used with the tourniquet lying within inches of the operative wound. We have found a 99% reduction in contamination of tourniquets by employing disinfectant wipes. This is a simple, cost-effective and quick method to clean tourniquets and we recommend the use of wipes before every case in addition to the manufactures guidelines for general cleaning of tourniquets

Primary total knee arthroplasty is associated with considerable blood loss, and allergenic blood transfusions are frequently necessary. Because of the cost and risks of allogenic blood transfusions, the autologous drainage blood reinfusion technique has been developed as an alternative. A number of studies have compared reinfusion techniques with standard suction drainage, but few reports compared with no drain use. We analyzed early results after primary total knee arthroplasty using autologous drainage blood reinfusion and no drain. We selected 30 patients who underwent primary total knee arthroplasty using no drain between November 2005 and March 2006 and matched for age and gender with 30 patients who underwent primary total knee arthroplasty using autologous drainage blood reinfusion technique between January 2003 and October 2005. All operations were done under pneumatic tourniquet and meticulous hemostasis was performed after deflation of the tourniquet. We have retrospectively reviewed the preoperative data (age, gender, body mass index, diagnosis, history of the knee surgery, infection and anticoagulant therapy, and medical cormorbidities) and the postoperative data (hemoglobin, hematocrit and platelet during hospitalization, the amount of allogenic blood transfusion and narcotics, complications, rehabilitation process, and clinical scores). All preoperative and postoperative variables except the postoperative second and seventh days hemoglobin and 2nd day hematocrit showed no significant differences between two groups. The hemoglobin and hematocrit also showed no significant differences at the postoperative fourteenth day. The autologous drainage blood reinfusion method in primary total knee arthroplasty does not have significant clinical benefit over no-drain method with regards to allogenic blood transfusions, narcotics uses, the incidence of complications and rehabilitation processes

Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis of the knee. Despite developments in prophylactic methods, deep venous thrombosis (DVT) and pulmonary embolism (PE) continue to be a serious complication following TKA. Otherwise DVT/PE is known to be a relatively low incidence in Asian patients, its accurate incidence is still controversial. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. Methods. We prospectively investigated 51 patients who underwent primary TKA at the hospital from July 2013 to December 2013. All were of Japanese ethnicity. The mean age at the surgery was 74.9 years and average BMI was 26.0. There were 45 (88.2%) cases of osteoarthritis and 5 (9.8%) of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses by utilizing pneumatic tourniquet. There were 21 cases of one-staged bilateral TKA and 30 of unilateral TKA. All patients were applied intermittent pneumatic compression (IPC) until 24 hours and graduated compression stockings for 3[高木1] weeks after the operation. Beginning from the day after the surgery, the patients were allowed walking with walker, along with the gradual range of motion exercise for physical thromboprophylaxis. Low-dose unfractionated heparin (LDUH) as a chemical thromboprophylaxis was administered subcutaneously for 3 days after the surgery. Informed consent was obtained regarding this thromboprophylaxis protocol. CE-CT and venous US were performed at the 4th day after surgery and images were read by a single senior radiologist team. The patients without DVT/PE by examination, they did not take additional chemical thromboprophylaxis. In cases of existence of DVT, continuous heparin administration and oral warfarin were applied and adjusted in appropriate dose for treatment. Warfarin was continued to be applied for at least three months until the patients had no symptoms and normal D-dimer level. In cases of PE, additional ultrasonic echocardiography (UCG) was performed, and then we consulted cardiologist to treat for PE. Results. CE-CT was performed in 42 patients (82.3%), otherwise nine patients (17.7%) could not take the examination because of exclusion criteria. There was no side-effect regard to contrast medium. The incidence of DVT and/or PE was 32 patients (62.7%), including two PE (3.9%), 21 DVT (41.1%) and nine both PE and DVT (17.6%). Six-teen patients were used LDUH routinely for 3 days after surgery. Five patients were used continuous heparin administration and oral warfarin instead of using LDUH because of medical co-morbidities. Additional continuous heparin administration and oral warfarin after LDUH use was needed in 26 patients. Three patients who had duodenal ulcer with chronic pancreatitis, massive PE with right heart strain and multiple DVT/PE with HIT antibody were needed another treatment. Conclusion. We prospectively investigated 51 patients for DVT/PE after primary TKA using CE-CT and venous US. The incidence of DVT/PE after primary TKA was 62.7%, including 21.5% of PE, as high frequency in Japanese patients

Introduction: Surgery and the use of pneumatic tourniquets lead to an increase in the activity of the fibrinolytic system, which in turn may accentuate the blood loss during knee arthroplasty. Drugs that inhibit the fibrinolytic system may thus be used to reduce blood loss. Tranexamic acid (TA) acts by binding to one of the enzymes at the start of the coagulation cascade, so inhibiting the fibrinolytic system. A concern is that this inhibition may have the side effect of increasing thromboembolic disease, a common complication of joint replacement surgery. We aim to confirm the reductions in blood loss and to assess the impact of TA usage on clinical and sub-clinical DVT. Method: We performed a prospective, randomised, double blind, controlled trial, using patients due to undergo primary unilateral total knee arthroplasty. Patients were randomised to receive either 15mg/kg of tranexamic acid or a similar volume of normal saline at the time of cementing of the prosthesis. Perioperative blood loss was recorded and patients were screened for DVT with duplex ultrasound assessment of both legs on the fifth post-operative day. Results: A statistically significant (p=0.006) decrease in blood loss in the early post operative period was noted in the group receiving tranexamic acid. This was not associated with a significant difference in total blood loss (p=0.55) or in transfusion requirements. There was no evidence of DVT in either group on duplex ultrasound screening of the lower limbs. Interpretation: One injection of 15mg/kg of tranexamic given at the time of cementing the prosthesis in total knee arthroplasty, before deflation of the tourniquet, significantly decreases the amount of blood loss in the early post operative period. The treatment was not associated with an increase in thromboembolic complications

Today the use of pneumatic tourniquet is commonly accepted in total knee arthroplasty (TKA) to reduce perioperative blood loss. There are a few prospective randomised and nonrandomised studies that compare the effect of tourniquet release timing in cementless or cemented unilateral TKA. However, many of these studies show an inadequate reporting and methodology. This randomized prospective study was designed to investigate the efficiency of tourniquet release timing in preventing perioperative blood loss in a simultaneous bilateral TKA study design. To our knowledge, this is the first study of its kind, in which the effect of tourniquet release timing on perioperative blood loss was investigated in simultaneous bilateral cemented TKA. In 20 patients (40 knees) one knee was operated with tourniquet release and hemostasis before wound closure, and the other knee with tourniquet release after wound closure and pressure dressing. To determine the order of tourniquet release technique for simultaneous bilateral TKA, patients were randomized in two groups: ‘Group A’ first knee with tourniquet release and hemostasis before wound closure, and ‘Group B’ second knee with tourniquet release and hemostasis before wound closure. The blood loss was recorded 48 hours postoperative for each technique. We found no significant difference in total blood loss between both techniques (p =.930), but a significant difference in operating time (p =.035). There were no postoperative complications at a follow-up of 6 month. Other studies report an increase the blood loss in early tourniquet release and an increase the risk of early postoperative complications in deflation of tourniquet after wound closure. In this study we found no significant difference in perioperative blood loss and no increase of postoperative complications. Therefore, we recommend a tourniquet release after wound closure to reduce the duration of TKA procedure and to avoid possible risks of extended anaesthesia