Summary

Systematic review and meta-analysis of the effects of non-tourniquet use during HTO

Abstract

Background

The use of tourniquet is common in lower limb orthopedic surgeries, such as fractures and total knee arthroplasty. Previous systematic reviews have shown that the tourniquet use is associated with a reduced time procedure and an increased incidence of complications. Although high tibial osteotomy (HTO) is an effective procedure for treating medial osteoarthritis, the effects of non-tourniquet use during HTO remain controversial. We hypothesized that postoperative pain after HTO in non-tourniquet group was lower than that in tourniquet group. Thus, the purpose of this systematic review was to assess clinical outcomes, including postoperative pain during HTO with or without a tourniquet.

Methods

This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines and registered in PROSPERO (CRD42024557931). The PubMed, Cochrane Library and Scopus were searched to identify randomized controlled trials (RCTs) and non-RCTs published before July 31, 2024. Search terms included (“high tibial osteotomy” OR “HTO” and “tourniquet”). Meta-analysis was performed using a random-effects model. The primary outcome was postoperative pain measured using the visual analogue scale (VAS). The secondary outcomes were operative time, total blood loss and deep vein thrombosis (DVT). All statistical analyses were performed using “EZR” (Easy R) and p value < 0.05 was considered statistically significant. The Methodological Index for Non-randomized Studies (MINORS) appraisal tool was used to evaluate the quality of studies.

Results

The initial search identified 76 articles (PubMed = 29, Cochrane library = 13, Scopus = 34). After removing duplicates, 33 articles remained. After title and abstract screening, 8 articles were excluded by following reasons: clinical trial (n = 4), non-English paper (n = 3), book chapter (n = 1). Of the 25 articles assessed for eligibility, 22 articles were excluded: clinical studies not related to this study (n = 17), Technical note (n = 3), case report (n = 1), review article (n = 1). Three studies (2 RCT and 1 retrospective cohort) with 217 patients (94 males and 123 females) were included. 103 patients were in the non-tourniquet group and 114 patients in the tourniquet group. The mean MINORS score in this study was 17.7. Meta-analysis showed VAS scores at 1- and 3 days postoperatively were significantly lower in the non-tourniquet group compared to the tourniquet group (postoperative 1-day: mean difference (MD) -0.91; 95% Confidence Interval (CI) -1.30 - -0.52; p<0.001, postoperative 3-day: MD -0.64; 95% CI -0.64 - -0.31; p=0.0002). However, no significant difference was observed in VAS score at 3 month postoperatively between the two groups (MD 0.06; 95% CI -0.20 – 0.31; p=0.65). Additionally, no significant differences were found in operation time, total blood loss and incidence of DVT between the two groups (operation time: MD 2.75; 95% CI -1.68 – 7.19; p=0.2238, total blood loss: MD 7.96; 95%CI -14.71 – 30.63; p=0.4914, DVT: Odds ratio 0.52; 95%CI 0.12 – 2.30; p=0.3901).

Conclusions

HTO without a tourniquet reduces postoperative pain at 1- and 3 day postoperatively and does not increase the operative time, total blood loss and incidence of DVT.