Blood loss is a major concern in total knee arthroplasty (TKA) along with postoperative knee function. The present study explores the impact of tourniquet and closed-suction drains on blood loss as well as knee function in TKA.

A prospective clinical trial was conducted on 111 patients admitted for TKA. Subjects were divided into three groups based on duration of tourniquet use (T+: whole-course tourniquet, T-: cementation only tourniquet) and usage of closed-suction drain (D+: drain use, D-: no drain). Thirty-six subjects were included in group T+D+, 42 in T-D+ and 33 in T-D-. Data from study population was analysed for pre and post-operative hemoglobin level (Hb), perioperative and total blood loss, blood transfusion rates, knee range of motion (ROM), and pain level assessment. Direct and indirect costs associated to nursing time and drains were calculated. Results are presented in mean ± SD.

No statistically significant differences were observed among the three groups (T+D+, T-D+ and T-D-) concerning total blood lost (calculated using Gross' formula), Hb levels over the first six postoperative weeks, blood transfusion rates and intra-articular hematomas. Intraoperative bleeding was significantly reduced in T+ subjects compared to T- subjects (100 ± 88 mL vs. 279 ± 235 mL respectively, p < 0.001), yet length of surgery was unaffected by the different tourniquet inflation strategies. Hidden blood loss was lower in D+ subjects compared to D- subjects (1161 ± 554 mL vs. 1667 ± 554 mL respectively, p < 0.001), but it was compensated by the blood loss in the drains. Early post operative ROM (flexion: 79.1 ± 14.8°, extension: −5.0 ± 6.7°) was superior in group T-D- compared to group T+D+ (flexion: 71.9 ± 17.1°, p = 0.071°; extension: −9.9 ± 6.4°, p = 0.004). Nevertheless, ROM six weeks postoperative was not statistically different between groups (flexion: 114.0 ± 13.3°, extension: 0.4 ± 5.2°). Patient-reported postoperative pain was also similar in all groups. Nursing time dedicated to drain management was 30 min/patient (330h total for 660 patients/year). Total costs related to drains were $31.92CAD/patient ($21,067CAD total for 660 patients/year).

Our results suggest that whole-course tourniquet and closed-suction drain use in TKA do not yield beneficial results in total blood loss, blood transfusion rates, complication rates and knee rehabilitation. Their clinical relevance in TKA is questionable. Moreover, nursing time and costs related to drains should have been allocated elsewhere in patient care.

Treat to target is the use of a physiologic marker as a monitor of effectiveness or compliance to an intervention. A recent example has been the progressive use of CTX-1 (Marker of osteoclastic activity) as a surrogate of bone resorptive activity in osteoporosis treatment. CTX-1 levels were demonstrated to be inversely related to drug efficacy in the suppression of bone resorption. As far as fragility fractures are concerned, no reference value of CTX-1 for any index fracture sites was found in the literature. In order to prevent subsequent fractures, efforts to better manage this chronic disease are to be explored. The main objective of this study was to compare and validate the use of serum CTX-1 to the perceived compliance to treatment.

Five hundred and forty three patients (men and women) 40 years of age or older who had been treated for a fragility fracture were enrolled. The purpose of this study was to correlate the measurement of CTX-1 with the perceived compliance to treatment of patients at the time of fracture and at six, 12 and 18 months after initiation of treatment. Our secondary objectives were to evaluate two different CTX-1 suppression target levels (CTX-1< 0.3 ng/mL and CTX-1<0.2 ng/mL), to determine CTX-1 values according to fracture sites, and to explore the profile of patients with subsequent fractures.

Considering index fractures, compliant patients under treatment at baseline had lower CTX-1 levels than non-compliant patients (p=0.052). Patients who were compliant to treatment at six, 12 and 18 months also had lower CTX-1 levels than non-compliant patients (p=0.000). When index fractures were divided into fracture sites, regardless of CTX-1 suppression target level (i.e. CTX-1< 0.3 or 0.2 ng/mL), significant CTX-1 suppression was observed in non-hip and non-vertebral (NHNV) fractures at six, 12 and 18 months (p0.05). No clinically relevant difference was observed between the profile of patients with and without subsequent fractures.

The correlation between serum CTX-1 at the time of fracture and at six, 12, 18 months and the perceived compliance to treatment was validated for NHNV fractures supporting the concept of the available treatments and their effects on bone remodeling for this type of fracture. The correlation was not validated for hip neither for vertebral fracture. There was no correlation between CTX-1 levels and subsequent fracture risk.