Effect of flexion/extension splintage post total knee arthroplasty on blood loss and range of motion — A randomised controlled trial

doi:10.1016/j.knee.2007.09.004

The Knee

Volume 15, Issue 1, January 2008, Pages 15-19

https://doi.org/10.1016/j.knee.2007.09.004 Get rights and content

Abstract

Previous published research has shown promising results with flexion splinting post total knee arthroplasty. Before instituting this practice, we conducted a randomised controlled trial to confirm any benefits over splinting in extension. Five patients were recruited into the trial. 5 were excluded. The flexion group consisted of 49 patients who had their knee placed in 70° of flexion over an inactive CPM machine for 24 h post operation. The extension group consisted of 46 patients who were splinted in full extension for the first 24 h post operation. We assessed post-operative day 1 drain volume, haemoglobin and haematocrit, blood transfusions, duration of inpatient stay, range of motion and complications within 6 weeks of surgery. There was no significant difference between the two groups among any of the outcomes measured. As such, we have been unable to demonstrate any benefit with splintage in flexion post total knee arthroplasty and have not adopted it as part of our post-operative management.

Introduction

Immediate post-operative limb positioning has been postulated to be a contributing factor in patient outcome with respect to range of motion and blood loss following total knee replacement surgery [1], [2], [3]. Although much research has been carried out with various protocols, ideal management remains varied and controversial.

Traditionally, positioning post total knee arthroplasty has been in extension with a compressive dressing applied and or an extension splint to reduce blood loss. However, this approach is being questioned. Horton et al. found that rehabilitation without a splint versus rehabilitation in a semi-rigid extension splint does not appear to change rates of complications, blood transfusion requirements, length of post-operative stay or post-operative range of motion [4]. Zenios et al. found that extension splinting in the rehabilitation phase resulted in decreased flexion at 6 weeks post operation but also less wound drainage, though transfusion rates were the same when compared to wool and crepe bandaging for the first 48 h post-op [5].

Furthermore, some studies [1], [2], [3] have reported significantly better results with flexion regimes with respect to drain volume, calculated fall in haemoglobin, length of stay and 6 week post-operative range of motion compared to extension positioning post-op.

Post-operative flexion of total knee arthroplasty, if proven to be beneficial with respect to post-operative blood loss, transfusion requirements and long term range of motion could be an elegant, simple and cost effective method to maximise patient outcomes. If it minimises blood loss, then transfusion and its associated risks may be avoided [6], [7].

Before instituting change, this study was performed to investigate the reported benefits of flexion splinting post knee arthroplasty. To ensure the methodological quality of the trial and enable future meta-analysis, the study was randomised, and followed the CONSORT criteria [8], [9](a framework developed by an international group of clinical trialists, statisticians, epidemiologists and biomedical editors to improve the reports of randomised controlled trials).

Section snippets

Materials and methods

This study was approved by the Sir Charles Gairdner Research Governance Unit.

Three consecutive patients having total knee arthroplasty under the 3 participating consultants were enrolled into the study from either Sir Charles Gairdner Hospital or Hollywood Private Hospital from Sept 2005 to July 2006. Patients were excluded from the study if they had coagulation defects, were on anticoagulants for an existing medical condition (e.g. chronic atrial fibrillation) or had excessive deformity

Results

The results are summarised in Table 3. There was no statistically significant difference (P < 0.05) between the flexion and extension group for average drain volume, fall in haemoglobin, fall in haematocrit, blood transfused by day 1, length of stay or range of motion at 6 weeks post operation. There were similar complications at 6 weeks post operation between the two groups.

On subgroup analysis, when patients who received transfusions in the first 24 h were excluded, there was still no

Discussion

Post-operative splinting of the knee either in flexion or extension is easy to do. If it were to impact significantly on blood loss, length of stay or range of motion without an increase in side effects it could potentially improve patient outcomes and satisfaction whilst decreasing the strain on hospital resources such as staffing, beds, blood transfusions and expensive equipment such as cell salvage systems. Currently, published studies [1], [2], [3], have reported promising but inconsistent

Acknowledgements

Many thanks to Jude Corbett RN at Hollywood Private Hospital and the many orthopaedic residents and registrars who helped track patients and collect data.

References (12)

OngS.M. et al.
Can knee position save blood following total knee replacement?
Knee
(2003 Mar)
B.A. Hewitt et al.
Flexion vs extension: a comparison of post-operative total knee arthroplasty mobilisation regimes
Knee
(2001 Dec)
HortonT.C. et al.
Is routine splintage following primary total knee replacement necessary? A prospective randomised trial
Knee
(2002)
ZeniosM. et al.
The use of knee splints after total knee replacements
Knee
(2002 Sep)
CallaghanJ.J. et al.
Blood management-issues and options
J Arthroplast
(2005)
SpeckM. et al.
Blood loss after total knee arthroplasty in relation to positioning 70 degrees flexion vs extension
J Bone Jt Surg
(1999)

There are more references available in the full text version of this article.

Cited by (31)

Effect of different postoperative limb positions on blood loss and range of motion in total knee arthroplasty: An updated meta-analysis of randomized controlled trials
2017, International Journal of Surgery
Citation Excerpt :
Three of the studies in this meta-analysis used the posterior cruciate ligament and substituted the total knee prosthetic component [13,19,22], one utilized a posterior-stabilized fixed TKA [15], and one used a cementless LCS rotating platform prosthesis [24] and a fixed bearing Journey Bi-Cruciate Stabilized prosthesis [16]. A tourniquet was applied in five studies [14–16,19,24], and drainage was used in seven studies [10,11,13–16,19]. Five studies were performed using an intramedullary femoral canal [13,15,19,22,24], while one study utilized both femoral and tibial intramedullary canals [11].
Postoperative limb positioning has been reported to be an efficient and simple way to reduce blood loss and improve range of motion following total knee arthroplasty (TKA). This meta-analysis was designed to compare the effectiveness of two different limb positions in primary TKA.
A meta-analysis of the PubMed, CENTRAL, Web of Science, EMBASE and Google Search Engine electronic databases was performed. In this meta-analysis, two postoperative limb positions were considered: mild-flexion (flexion less than 60°) and high-flexion (flexion at 60° or more). The subgroups were analysed using RevMan 5.3.
Nine RCTs were included with a total sample size of 913 patients. The mild- and high-flexion positions significantly reduced postoperative total blood loss (P = 0.04 and P = 0.01; respectively). Subgroup analysis indicated that knee flexion significantly reduced hidden blood loss when the knee was fixed in mild-flexion (P = 0.0004) and significantly reduced transfusion requirements (P = 0.03) and improved range of motion (ROM) (P < 0.00001) when the knee was fixed in high-flexion. However, the rates of wound-related infection, deep venous thrombosis (DVT) and pulmonary embolism (PE) did not significantly differ between the two flexion groups.
This meta-analysis suggests that mild- and high-flexion positions have similar efficacy in reducing total blood loss. In addition, subgroup analysis indicates that the mild-flexion position is superior in decreasing hidden blood loss compared with high-flexion; the high-flexion position is superior to mild–flexion in reducing transfusion requirements and improving postoperative ROM. Thus, the use of the high-flexion position is a viable option to reduce blood loss in patients following primary TKA without increasing the risk of wound-related infection, DVT or PE.
Leg position influences early blood loss and functional recovery following total knee arthroplasty: A randomized study
2015, International Journal of Surgery
Hidden blood loss is a major factor influencing functional recovery and quality of life in patients undergoing total knee arthroplasty. Special hip and knee flexion positions after have been reported to have promising results with respect to reducing perioperative blood loss. The purpose of this study was to determine the effect of postoperative leg position on blood loss and functional recovery after total knee arthroplasty.
We enrolled 46 consecutive patients with degenerative osteoarthritis of the knee in this prospective, randomized study. The patients were randomly allocated to a flexion or an extension group. In the flexion group, the affected leg was elevated by 60° at the hip, and the knee was flexed by 60°, while in the extension group, the affected knee was fully extended postoperatively. Blood loss, hemoglobin level, knee circumference and range of motion (ROM) were recorded to determine the influence of postoperative leg position on clinical outcomes.
Although the transfusion rate was similar between the two groups (P > 0.05), other parameters related to blood loss (including calculated blood loss, hidden blood loss and postoperative knee circumference) were significantly lower in the flexion group than in the extension group (P < 0.05). After 6 weeks of rehabilitation, patients from the flexion group had gained a better ROM in the affected knee than had patients from the extension group (P = 0.04). At 6 months, however, the ROM of the affected knee was similar in both groups. The hospital stay was 1.9 days shorter in the flexion group than in the extension group. Wound infection rates were similar in both groups, and no proven case of deep vein thrombosis was observed in either group.
Elevation of the hip by 60° with 60° knee flexion is an effective and simple method to reduce blood loss after primary unilateral total knee arthroplasty, and contributes to better recovery of the functional ROM in the early postoperative period.
A randomised controlled trial investigating the effect of posterior capsular stripping on knee flexion and range of motion in patients undergoing primary knee arthroplasty
2011, Knee
Increasing knee flexion following total knee arthroplasty (TKA) has become an important outcome measure. Surgical technique is one factor that can influence knee motion.
In this study, it was hypothesised that stripping of the posterior knee capsule could improve flexion and range of motion (ROM) following TKA.
Patients who were undergoing TKA were prospectively randomised into two groups — one group (62 patients) were allocated stripping of the posterior knee capsule (PCS), the other group (66 patients) no stripping (no-PCS).
The primary outcome was change in flexion and ROM compared to pre-operative measurements at three time points; after wound closure, 3 months and 1 year post-operatively. Secondary outcomes were absolute measurements of flexion, extension, ROM and complications. All operations were performed by a single surgeon using the same implant and technique. All patients received identical post-operative rehabilitation.
There was a significant gain in flexion after wound closure in the PCS group (p = 0.022), however there was no significant difference at 3 months or 1 year post-operatively. Absolute values of extension (p = 0.008) and flexion (p = 0.001) 3 months post-operatively were significantly reduced for the PCS group. The absolute value of ROM was significantly higher for the no-PCS group at 3 months (p = 0.0002) and 1 year (p = 0.005).There were no significant difference in the rate of complications.
Posterior capsular stripping causes a transient increase in flexion that does not persist post-operatively. We do not recommend routine stripping of the posterior knee capsule in patients undergoing TKA.
Blood loss following total knee replacement in the morbidly obese: Effects of computer navigation
2011, Knee
Computer navigated total knee arthroplasty (TKA) has several proposed benefits including reduced post-operative blood loss. We compared the total blood volume loss in a cohort of morbidly obese (BMI > 40) patients undergoing computer navigated (n = 30) or standard intramedullary techniques (n = 30) with a cohort of matched patients with a BMI < 30 also undergoing navigated (n = 31) or standard TKA (n = 31). Total body blood loss was calculated from body weight, height and haemotocrit change, using a model which accurately assesses true blood loss as was maximum allowable blood loss which represents the volume of blood that can be lost until a transfusion trigger is required. The groups were matched for age, gender, diagnosis and operative technique.
The mean true blood volume loss across all BMI's was significantly (p < 0.001) less in the computer assisted group (1014 ± 312 ml) compared to the conventional group (1287 ± 330 ml). Patients with a BMI > 40 and a computer navigated procedure (1105 ± 321 ml) had a significantly lower (p < 0.001) blood volume loss compared to those who underwent a conventional TKA (1399 ± 330 ml). There was no significant difference in the transfusion rate or those reaching the maximum allowable blood loss between groups.
This study confirms a significant reduction in total body blood loss between computer assisted and conventional TKA in morbidly obese patients. However computer navigation did not affect the transfusion rate or those reaching the transfusion trigger in the morbidly obese group. Therefore computer navigation may reduce blood loss in the morbidly obese patient but this may not be clinically relevant to transfusion requirements as previously suggested.
Qualitative and quantitative analysis of post-operative drainage: pilot study
2023, Acta Orthopaedica Belgica
Effect of joint immobilization using extension splint immediately after total knee arthroplasty on post-operative knee function and pain: a randomized clinical trial
2022, International Orthopaedics

View all citing articles on Scopus

¹: Tel.: +61 8 9346 3333.

View full text

Effect of flexion/extension splintage post total knee arthroplasty on blood loss and range of motion — A randomised controlled trial

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Knee

Knee

Knee

Knee

J Arthroplast

Blood loss after total knee arthroplasty in relation to positioning 70 degrees flexion vs extension

J Bone Jt Surg