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Effect of removing the ischaemia tourniquet on the transfusion needs of the patient undergoing primary knee arthroplasty
Efecto de la retirada del manguito de isquemia sobre las necesidades transfusionales en el paciente intervenido de artroplastia primaria de rodilla
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Paredes-Carnero, G.L. Rosero-Ruíz, J.J. Centeno-García, F.J. Pombo-Taboada" "autores" => array:4 [ 0 => array:4 [ "nombre" => "X." "apellidos" => "Paredes-Carnero" "email" => array:1 [ 0 => "xavinef@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "G.L." "apellidos" => "Rosero-Ruíz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.J." "apellidos" => "Centeno-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F.J." 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It is estimated that a decrease of 1000<span class="elsevierStyleHsp" style=""></span>ml represents the loss of 3<span class="elsevierStyleHsp" style=""></span>gr/dl of haemoglobin (Hb).<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> In our environment, a marked decrease in postoperative Hb is treated by transfusion of packed red blood cells (PRBC), however, this measurement is accompanied by an increase in morbidity and mortality,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> which take the form of infections, coagulopathies, immunosuppression, pulmonary lesions, disease transmission, etc. The criteria to carry out a transfusion are not always well defined, leaving the decision to the physician based on the symptoms and Hb levels in venous blood. However, these levels are not always completely reliable in the immediate postoperative period, which makes the clinical data essential in such situations (hypotension, tachycardia, pallor, decreased reactiveness, etc.).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Traditionally, a tourniquet applied through a pneumatic cuff placed in the thigh has been used to minimise perioperative blood loss. This causes ischaemia at the distal level of the cuff, which reduces intraoperative bleeding, and, in addition to entailing a decrease in patient morbidity and mortality, improves the view of the surgical field and favours the cementing technique. Nevertheless, this use is controversial, as it has been demonstrated that in 5<span class="elsevierStyleHsp" style=""></span>min immediately after the release of the cuff there is an increase in reactive bleeding.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> In addition, the use of ischaemia seems to be a risk factor for deep vein thrombosis and greater postoperative pain due to neurovascular compression.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4–7</span></a> On the other hand, some data show improved lateral tracking of the patella with the use of the cuff, due to the action of the <span class="elsevierStyleItalic">vastus lateralis</span>.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The use of an ischaemia cuff was implemented in our environment in parallel to the knee prosthesis surgery itself and, at present, 100% of knee arthroplasties are carried out with a tourniquet. Nevertheless, the ideal way to remove the cuff is still under discussion, as there are two different possibilities: one advocates removing the ischaemia after cementing, prior to closing the surgical wound, carrying out haemostasis in the same action, whilst the other recommends removal after the closure, after applying a compressive bandage on the joint. Advocates of the first method argue the convenience of performing haemostasis through diathermic coagulation, as there is a periarticular arterial network (mainly the geniculated arteries deriving from the popliteal artery) which, if affected, would cause a haemorrhage. Those authors who opt for removing the ischaemia cuff after closing the surgical wound assure that an adequate approach avoids the geniculated arteries, and that the duration of surgery is reduced if haemostasis is not carried out, thus providing the added benefit of reducing haemorrhage and infection.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The majority of studies conducted show greater blood loss by removing the cuff before closure,<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10–15</span></a> when the lost blood is measured by an estimated calculation based on the Hb decrease in relation to the body mass index,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> whilst only one study has found greater blood loss by removing after closure.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Nevertheless, an increased need for transfusions has been confirmed with cuff removal prior to closure, as shown by the metaanalysis of Rama et al.,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> 28.6% versus 21.1%. In cases where the lost blood is measured directly (Hb, Hct, drainage, etc.) there are no differences in most studies<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10–12,18–25</span></a>; only Yildiz et al.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> found differences in the mean direct blood loss (Hb). Thus, there is a notable error linked to imprecise measurements obtained postoperatively, as their variability is very high.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand, there is a higher rate of local complications when the tourniquet is removed after closure,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> such as wound complications, deep vein thrombosis or the postoperative need for joint manipulation. There are also more reinterventions with release after closure, 3.1% versus 0.3%.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Furthermore, the use of a blood recovery system has not been linked with an increased need for transfusions based on whether it is removed before the cuff or after.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore, given this difference of results, and since there is a disparity regarding cuff removal in our hospital, we intend to review our series and verify the difference in terms of postoperative bleeding and clinical repercussions, manifested by normocytic and normochromic anaemia, with the subsequent increase in blood transfusions and possible complications derived thereof.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">We retrospectively analysed 201 surgical interventions for primary total knee arthroplasty. We included patients aged between 55 and 85 years. We excluded patients who underwent anticoagulant or antiaggregant therapy (we did not take into consideration 100<span class="elsevierStyleHsp" style=""></span>mg of acetyl salicylic acid and low molecular weight heparins) due to the variability in removal and reintroduction of these drugs based on the criteria of the surgeon, which could generate a bias among these patients. We did not include patients with coagulopathies, thrombopathies and other haematological diseases which affected haemostasis. Patients presented minimum preoperative Hb levels of 10<span class="elsevierStyleHsp" style=""></span>gr/dl. Patients received one dose of low molecular weight heparin 12<span class="elsevierStyleHsp" style=""></span>h before surgery, another 6<span class="elsevierStyleHsp" style=""></span>h after the procedure, and then it was administered every 24<span class="elsevierStyleHsp" style=""></span>h for 10 days.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients were operated on between June 30th 2010 and December 31st 2013. Patient data was obtained from their clinical histories, held by the archive of the hospital. We obtained approval from the regional committee for ethics and scientific research.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A total of eight surgeons specialising in Orthopaedic Surgery and Traumatology were responsible for the interventions.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgery</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients were divided into two groups: one where the ischaemia cuff was removed prior to closing the surgical wound (group A) and another one where it was removed after closure (group B). The pneumatic cuff was placed in the proximal end of the thigh and inflated prior to the surgery at a pressure of between 270 and 350<span class="elsevierStyleHsp" style=""></span>mmHg. A classical medial parapatellar approach was used in all cases. All the knee arthroplasties were stabilised posteriorly. In surgeries in which the cuff was removed before wound closure, the pressure was not loosened until cementing was completed. After applying compression on the surgical area with gauzes, haemostasis was carried out with a diathermic scalpel until it was confirmed that no vessels continued to bleed actively. Next, the surgical wound was closed, placing a drainage bulb or else a blood conservation system from the interior to the exterior of the joint. After this, a bandage was applied on the entire lower limb. The other alternative was to remove the cuff after closing the surgical wound (also leaving a drainage or recovery system) and applying a compressive bandage on the lower limb after the closure. The data on the method of tourniquet removal were extracted from the surgical protocol of the intervention, and contrasted with the protocols for nursing and anaesthesia. The choice of tourniquet removal method was the responsibility of each principal surgeon and was kept the same for all the interventions of each individual surgeon (except for one surgeon, who carried out two interventions with one method and the rest with another). Both the femoral and the tibial components were cemented in all the arthroplasties, as well as the patella, if this was replaced.</p><p id="par0060" class="elsevierStylePara elsevierViewall">After the intervention, patients were taken to the reanimation area and from there to the Traumatology Service after 3–4<span class="elsevierStyleHsp" style=""></span>h. The transfused blood was counted by collecting the data from the nursing history in the reanimation area and in the Traumatology Service. We took into account the number of transfused PRBC. We also considered autotransfusion with blood from the recovery system, counting every 250<span class="elsevierStyleHsp" style=""></span>ml of recovered blood as 1 PRBC. The transfusion criteria were analytical, with an Hb level under 8<span class="elsevierStyleHsp" style=""></span>gr/dl without comorbidities, or 10<span class="elsevierStyleHsp" style=""></span>gr/dl with associated comorbidities or clear symptoms of anaemia. The symptoms were the reason for the decision to start transfusion during the stay in the reanimation room (based on systolic hypotension <80<span class="elsevierStyleHsp" style=""></span>mmHg, tachycardia >120<span class="elsevierStyleHsp" style=""></span>lpm or unreactive condition, with skin and mucosal pallor). We took into account the PRBC transfused during hospital admission in the Traumatology Service in the 72<span class="elsevierStyleHsp" style=""></span>h after the intervention. The choice of blood recovery or drainage depended on the decision adopted by each surgeon during the intervention.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The monitoring of complications was carried out following the clinical history of each patient, from the intervention until the present moment. We took into account acute complications (during the first month), as well as the subacute (during the first 6 months) and the chronic (after 6 months). We distinguished between infectious and mechanical complications which required readmission. In addition, infections were classified as superficial and deep.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The descriptive analysis of Gaussian variables was expressed as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation and that of the non-Gaussian as median and first-third quartile. The Kolmogorov–Smirnov test was conducted to assess the normality of the variables. Qualitative variables were expressed as frequencies and percentages.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We conducted nonparametric tests (Chi-squared and Mann–Whitney <span class="elsevierStyleItalic">U</span>) to determine the association between removal of the ischaemia cuff (before, after) and the study variables.</p><p id="par0080" class="elsevierStylePara elsevierViewall">A Mann–Whitney <span class="elsevierStyleItalic">U</span> test was carried out to verify if there were differences in surgery time between transfused and non-transfused patients.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Lastly, the Kruskal–Wallis test was applied to analyse the differences in surgery time between the different numbers of total PRBC. We also carried out multiple 2 on two comparisons using the Mann–Whitney <span class="elsevierStyleItalic">U</span> test with Bonferroni correction.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Differences of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 were considered as statistically significant in all cases. The analyses were carried out with the free software package R (<a href="http://www.r-project.org/"><span class="elsevierStyleUnderline">http://www.r-project.org</span></a>).</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 140 females (mean age of 72 years) and 61 males (mean age of 71 years) were intervened. A total of 101 patients underwent removal method A (prior to closure) and 100 underwent method B (after closure). There were no differences between groups in terms of age and gender. Each surgeon carried out a mean 25 arthroplasties (range: 18–31). The recovery system was applied to 32 patients and simple drainage was applied to the rest (169), with no differences between both groups regarding the use of the recovery system (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The mean duration of the intervention was 111<span class="elsevierStyleHsp" style=""></span>min in group A and 98<span class="elsevierStyleHsp" style=""></span>min in group B, with this difference being statistically significant (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The mean transfused PRBC was 0.62 in group A and 0.61 in group B, with no statistically significant differences between both groups. No correlation was established between the surgery time and the transfused PRBC (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.055), although there was tendency to have more transfusions among cases with a longer surgery time (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were 18 complications in total; 8 in group A and 10 in group B, with no differences between them. There were 12 infections (8 superficial and 4 deep). Among the 8 superficial, 7 were acute or subacute and 1 was chronic, whilst all the 4 deep cases were chronic and required replacement of the prosthesis in two stages. The results according to groups were the following: 5 in group A, 3 superficial and 2 deep, and 7 in group B, 5 superficial and 2 deep. There were no significant differences between both groups (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.69) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Our study did not find differences between removing the ischaemia cuff before or after closing the surgical wound, or regarding the need for transfusions, or in relation to postoperative complications. In the first of two metaanalyses on this topic, Rama et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> concluded that removing the tourniquet before closure increased the estimated postoperative bleeding. Zan et al.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> corroborated this finding in the last study conducted, whilst adding to this increase in blood loss the blood lost directly and the intraoperative loss. This loss could be explained by two reasons: on the one hand, the duration of surgery was increased, thus causing more bleeding, and on the other, there would be reactive haemorrhage after removing the cuff, which would increase the physiological bleeding.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> This result has been supported by an increased need for transfusions among these patients. In our series, the mean number of transfusions was far lower than in other studies, around 0.6 PRBC (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) per patient in both groups, which is in contrast with the values of 1.3 in removal prior to closure and 1.4 in removal after closure reported in the study by Harvey et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Similarly, Page et al.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> registered a mean value of 2.6 PRBC in both groups. This could be explained by various factors; firstly, the selection of patients in our study was very strict, as the number of subjects ruled out due to therapies and disease was almost 90, nearly 30% of the total arthroplasties performed, thus selecting our population and giving it less chance for intraoperative and postoperative complications, unlike most of the published studies, where prior treatments and protocols for removal of anticoagulation or antiaggregation are not specified. In addition, various studies do not specify the duration of surgery or the existence of differences between groups, a reason which seems to entail a greater postoperative blood loss.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> However, we did not find a direct relationship between the duration of surgery and the need for blood transfusions, although we did observe a tendency that was not statistically significant (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.055) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Urbano Manero and Miguelena Bobadilla<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> did not find differences in the number of transfusions (with mean values of 0.3 and 0.4 PRBC, similar to our results) between both groups, but they did find them between the blood lost intraoperatively and the total blood lost, which would not be consistent with an identical transfusion requirement with similar prior Hb levels. On the other hand, Abbas et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> obtained a decrease in the number of PRBC transfused in the group with intraoperative removal, compared to the group with postoperative removal, although, interestingly, they did not find any difference in the blood loss measured directly. We did find significant differences in duration of surgery between both groups (111<span class="elsevierStyleHsp" style=""></span>min in group A and 98<span class="elsevierStyleHsp" style=""></span>min in group B) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), as did Hersekli et al.,<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> who obtained a mean duration of surgery shorter than ours, but also superior in the case of removal prior to closure (87<span class="elsevierStyleHsp" style=""></span>min for prior removal and 80<span class="elsevierStyleHsp" style=""></span>min for subsequent removal), as well as Yavarikia et al. (104 versus 96<span class="elsevierStyleHsp" style=""></span>min).<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> Furthermore, Steffin et al.,<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> Barwell et al.,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> Burkhart et al.,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> and Newman et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> did not report any differences between both groups.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Thus, the reduction in transfusions could have influenced the possibility of finding differences between both groups. In any case, in our study we were only able to measure the blood lost through the need for transfusions, which confers a degree of subjectivity to the decision of transfusing patients. Likewise, it seems that the surgical technique plays a key role in postoperative bleeding, since a careful approach whilst recognising the vascular anatomy would avoid damaging the geniculated arteries, the main vessels responsible for bleeding in this intervention. The published studies comparing the surgical technique with both types of cuff removal do not report any cases of section of the popliteal artery. Likewise, in our series we did not register any cases, thus diminishing the importance of removal prior to closure in order to verify that the artery had not been affected.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The metaanalyses of Rama et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> and Zan et al.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> also compared the complications based on the time of tourniquet removal, with a different result to ours, since, in this case, removal prior to closure reduced the complications and the need for reintervention. This has been explained by the greater incidence of subcutaneous haematomas, which are produced after surgical closure when haemostasis is not carried out, which would cause an increase in ischaemia at a local level during the tissue recovery phase, with a subsequent predisposition towards infection and wound dehiscence. In addition, unlike Rama et al.,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> Zan et al.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> concluded that complications also increased in the group with removal after closure, in terms of rehabilitation and mobility. In our series we did not observe more complications with removal after closure. The number of severe complications was also low, and once again this could be explained by the characteristics of our patients, with less comorbidities and, therefore, less predisposed to complications, although the number of local complications, particularly superficial infections, was high. This reduction of complications also reduced the possibility of observing differences between both groups.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In light of our results, the point during the intervention at which ischaemia should be removed does not seem determinant in reducing blood transfusions. In any case, an in-depth knowledge of the vascular anatomy of the knee is essential to conduct the approach. Likewise, the postoperative complications seem to be more related to the characteristics of each patient, in terms of their comorbidities, than to the surgical technique applied. Further prospective studies would be necessary in order to determine the influence of ischaemia in blood loss, as well as the repercussion on complications deriving from ischaemia and blood transfusions.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres572753" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec589803" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres572754" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec589802" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Data" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgery" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-24" "fechaAceptado" => "2015-05-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec589803" "palabras" => array:4 [ 0 => "Arthroplasty" 1 => "Knee" 2 => "Ischaemia" 3 => "Transfusion" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec589802" "palabras" => array:4 [ 0 => "Artroplastia" 1 => "Rodilla" 2 => "Isquemia" 3 => "Transfusión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine the influence of the timing of the removal of the ischaemia tourniquet on the transfusion needs in primary knee arthroplasty and its influence on post-operative complications.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective analysis was performed on 201 primary knee arthroplasties. The patients were divided into two groups: group A (101 patients), where the tourniquet was removed before surgical closure, and group B (100 patients), where the tourniquet was removed after the surgical closure. A comparison was made of the blood transfusions (pools of red corpuscles) received by both groups, along with the surgical time, and the post-operative complications.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean number of packed red cells transfused in group A was 0.62, while in the group B it was 0.61 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.831). The mean time in the surgery in group A was 111<span class="elsevierStyleHsp" style=""></span>min, and in group B it was 98<span class="elsevierStyleHsp" style=""></span>min (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05), with no significant difference between the surgical time and the number of packed cells transfused (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.055). The post-operative complications in the group A were 8, and in the B were 10 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.79).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There were no differences between removing the tourniquet before or after surgical closure or in the transfusion needs or in the post-operative complications. Traditionally, the greater blood loss due to the removal of the tourniquet before surgical closure has been explained as due to the longer surgery time required. However, in the present study, this fact was not associated with greater transfusion needs, or with more post-operative complications.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Conocer la influencia del momento de la retirada del manguito de isquemia en la necesidad de transfusiones sanguíneas en las artroplastias primarias de rodilla y su influencia en las complicaciones postoperatorias.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fueron analizadas 201 artroplastias primarias de rodilla retrospectivamente. Se dividieron en 2 grupos: el grupo A (101 pacientes), en el que se retiró el manguito antes del cierre quirúrgico, y el grupo B (100 pacientes), en el que se retiró tras el cierre. Se compararon las transfusiones sanguíneas (medidas en concentrados de hematíes) llevadas a cabo por ambos grupos, contrastándolas con el tiempo quirúrgico, así como las complicaciones posquirúrgicas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La media de concentrados de hematíes transfundidos en el grupo A fue de 0,62, mientras que en el grupo B fue de 0,61 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,831). El tiempo medio quirúrgico en el grupo A fue de 111<span class="elsevierStyleHsp" style=""></span>min, y en el grupo B, de 98<span class="elsevierStyleHsp" style=""></span>min (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05), no existiendo relación entre el tiempo quirúrgico y los concentrados de hematíes transfundidos (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,055). Las complicaciones posquirúrgicas en el grupo A fueron 8, y en el B, 10 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,69).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No hubo diferencias entre retirar el manguito de isquemia antes o después del cierre quirúrgico, ni en las necesidades transfusionales ni en las complicaciones posquirúrgicas. Tradicionalmente las mayores pérdidas sanguíneas al retirar el manguito antes del cierre han sido explicadas por el mayor tiempo quirúrgico que se requiere; sin embargo, este hecho no se relacionó con mayores necesidades transfusionales en nuestro estudio, ni con mayores complicaciones posquirúrgicas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Paredes-Carnero X, Rosero-Ruíz GL, Centeno-García JJ, Pombo-Taboada FJ. Efecto de la retirada del manguito de isquemia sobre las necesidades transfusionales en el paciente intervenido de artroplastia primaria de rodilla. Rev Esp Cir Ortop Traumatol. 2015;59:394–399.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1473 "Ancho" => 1645 "Tamanyo" => 86431 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Influence of duration of surgery on the need for blood transfusions (measured in packed red blood cells).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PRBC: packed red blood cells.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Quantitative variables are represented by median (first-third quartile) and qualitative variables by absolute frequencies (percentages).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>201) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Removal before closure (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>101) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Removal after closure (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>100) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.32 (68.69–79.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73.52 (68.36–77.92) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75.62 (69.8–77.36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.365 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender (males) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">140 (69.65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 (68) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 (69.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.78 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of surgery (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104 (89–154) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">111 (89–154) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 (84.5–121) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood recovery system (yes) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (15.92) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (14.14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (22.22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.138 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total number of PRBC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61 (0–1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.62 (0–1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61 (0–1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.831 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complications (yes) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (8.95) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (0.49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.694 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transfused (yes) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (28.85) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (15.42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (13.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.731 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934755.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient data according to moment of pneumatic cuff removal.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">0 (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>139) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">1 (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">2 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>34) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">3 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">4 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">104 (90–120) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">107.5 (90–141.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">107.5 (87.75–142.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">132.5 (111.2–168.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">135 (122.2–172.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.055 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934756.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Mean duration of surgery based on the number of packed red blood cells transfused postoperatively.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hidden blood loss following hip and knee arthroplasty: correct management of blood loss should take hidden loss into account" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.R. 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| Year/Month | Html | Total | |
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| 2024 November | 6 | 0 | 6 |
| 2024 October | 9 | 10 | 19 |
| 2024 September | 6 | 14 | 20 |
| 2024 August | 16 | 17 | 33 |
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| 2024 February | 13 | 6 | 19 |
| 2024 January | 26 | 4 | 30 |
| 2023 December | 16 | 8 | 24 |
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| 2023 October | 23 | 6 | 29 |
| 2023 September | 16 | 1 | 17 |
| 2023 August | 22 | 4 | 26 |
| 2023 July | 12 | 3 | 15 |
| 2023 June | 16 | 5 | 21 |
| 2023 May | 39 | 6 | 45 |
| 2023 April | 47 | 4 | 51 |
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| 2023 February | 22 | 4 | 26 |
| 2023 January | 17 | 5 | 22 |
| 2022 December | 26 | 5 | 31 |
| 2022 November | 17 | 6 | 23 |
| 2022 October | 13 | 5 | 18 |
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| 2021 April | 18 | 10 | 28 |
| 2021 March | 10 | 7 | 17 |
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| 2021 January | 13 | 9 | 22 |
| 2020 December | 1 | 0 | 1 |
| 2018 February | 78 | 0 | 78 |
| 2018 January | 27 | 2 | 29 |
| 2017 December | 80 | 0 | 80 |
| 2017 November | 26 | 1 | 27 |
| 2016 December | 0 | 1 | 1 |
| 2016 November | 0 | 1 | 1 |
| 2016 September | 0 | 2 | 2 |
| 2016 July | 0 | 1 | 1 |
| 2016 June | 0 | 11 | 11 |
| 2016 March | 0 | 6 | 6 |
| 2016 January | 0 | 1 | 1 |
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