The influence of knee flexion position on postoperative blood loss and knee range of motion after total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WU Limin ^1,2 , WU Yuangang ¹ , SI Haibo ^1,2 , ZENG Yi ^1,2 , LIU Yuan ¹ , YANG Peng ¹ ,  SHEN Bin ¹

1. Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;
2. National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding?author：

SHEN Bin, Email: shenbin71@hotmail.com

Keywords：

Total knee arthroplasty; knee; flexion; postoperative blood loss; range of motion

DOI：

10.7507/1002-1892.201909058

Video：

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Objective To summarize research progress of the effect of knee flexion position on postoperative blood loss and knee range of motion (ROM) after total knee arthroplasty (TKA).Methods The relevant literature at home and abroad was reviewed and summarized from mechanism, research status, progress, and clinical outcome. The differences of clinical results caused by different positions, flexion angles, and keeping time were compared.Results Keeping knee flexion after TKA can reduce postoperative blood loss through the angle change of blood vessels and increase knee early ROM by improving flexion muscle strength. When the flexion angle of the knee is large and the flexion position is keeping for a long time, the postoperative blood loss and the knee ROM can be significantly improved. However, the amount of blood loss and ROM are not further improved in the patients with keeping knee flexion for more than 24 hours compared with less than 24 hours.Conclusion Keeping knee flexion after TKA is a simple and effective method to reduce postoperative blood loss and improve knee ROM. However, the optimal knee flexion angle and time are needed to be further explored.

Citation： WU Limin, WU Yuangang, SI Haibo, ZENG Yi, LIU Yuan, YANG Peng, SHEN Bin. The influence of knee flexion position on postoperative blood loss and knee range of motion after total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(4): 524-528. doi: 10.7507/1002-1892.201909058 Copy

1.	Losina E, Thornhill TS, Rome BN, et al. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg (Am), 2012, 94(3): 201-207.
2.	Weinstein AM, Rome BN, Reichmann WM, et al. Estimating the burden of total knee replacement in the United States. J Bone Joint Surg (Am), 2013, 95(5): 385-392.
3.	Carson JL, Stanworth SJ, Roubinian N, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev, 2016, 10: CD002042.
4.	Madjdpour C, Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth, 2005, 95(1): 33-42.
5.	Raut S, Mertes SC, Muniz-Terrera G, et al. Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75. Int Orthop, 2012, 36(8): 1601-1608.
6.	Voorn VM, Marang-van de Mheen PJ, So-Osman C, et al. Designing a strategy to implement cost-effective blood transfusion management in elective hip and knee arthroplasties: a study protocol. Implement Sci, 2012, 7: 58.
7.	Li B, Wang G, Wang Y, et al. Effect of two limb positions on venous hemodynamics and hidden blood loss following total knee arthroplasty. J Knee Surg, 2017, 30(1): 70-74.
8.	Li B, Wen Y, Wu H, et al. The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop, 2009, 33(5): 1263-1268.
9.	Zeng Y, Si H, Li C, et al. Effect of knee flexion position and combined application of tranexamic acid on blood loss following primary total knee arthroplasty: a prospective randomized controlled trial. Int Orthop, 2018, 42(3): 529-535.
10.	Ma T, Khan RJ, Carey Smith R, et al. Effect of flexion/extension splintage post total knee arthroplasty on blood loss and range of motion—a randomised controlled trial. Knee, 2008, 15(1): 15-19.
11.	Wu Y, Zeng Y, Li C, et al. The effect of post-operative limb positioning on blood loss and early outcomes after primary total knee arthroplasty: a randomized controlled trial. Int Orthop, 2019, 43(9): 2083-2091.
12.	De Fine M, Traina F, Giavaresi G, et al. Effect of different postoperative flexion regimes on the outcomes of total knee arthroplasty: randomized controlled trial. Knee Surg Sports Traumatol Arthrosc, 2017, 25(9): 2972-2977.
13.	Motififard M, Heidari M, Nemati A. No difference between wound closure in extension or flexion for range of motion following total knee arthroplasty: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 74-78.
14.	?ükür E, ?ztürkmen Y, Akman YE, et al. The effect of tourniquet and knee position during wound closure after total knee arthroplasty on early recovery of range of motion: a prospective, randomized study. Arch Orthop Trauma Surg, 2016, 136(12): 1773-1780.
15.	王海霞. 全膝關節置換術后不同下肢體位對患肢康復的影響. 中國實用醫藥, 2016, 11(14): 87-88.
16.	Yang Y, Yong-Ming L, Pei-jian D, et al. Leg position influences early blood loss and functional recovery following total knee arthroplasty: A randomized study. Int J Surg, 2015, 23(Pt A): 82-86.
17.	Liu J, Li YM, Cao JG, et al. Effects of knee position on blood loss following total knee arthroplasty: a randomized, controlled study. J Orthop Surg Res, 2015, 10: 69.
18.	K?mürcü E, Yüksel HY, Ersoz M, et al. Effect of surgical closing in total knee arthroplasty at flexion or extension: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc, 2014, 22(12): 3067-3073.
19.	Napier RJ, Bennett D, McConway J, et al. The influence of immediate knee flexion on blood loss and other parameters following total knee replacement. Bone Joint J, 2014, 96-B(2): 201-209.
20.	Panni AS, Cerciello S, Vasso M, et al. Knee flexion after total knee arthroplasty reduces blood loss. Knee Surg Sports Traumatol Arthrosc, 2014, 22(8): 1859-1864.
21.	Li B, Wen Y, Liu D, et al. The effect of knee position on blood loss and range of motion following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2012, 20(3): 594-599.
22.	王思群, 黃鋼勇, 夏軍, 等. 全膝關節置換術后膝關節位置對術后失血的影響. 中華關節外科雜志 (電子版), 2011, 5(2): 160-164.
23.	Ong SM, Taylor GJ. Can knee position save blood following total knee replacement? Knee, 2003, 10(1): 81-85.
24.	Wang HY, Yu GS, Li JH, et al. An updated meta-analysis evaluating limb management after total knee arthroplasty-what is the optimal method? J Orthop Surg Res, 2019, 14(1): 97.
25.	Wu Y, Yang T, Zeng Y, et al. 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. Int J Surg, 2017, 37: 15-23.
26.	Fu X, Tian P, Li ZJ, et al. Postoperative leg position following total knee arthroplasty influences blood loss and range of motion: a meta-analysis of randomized controlled trials. Curr Med Res Opin, 2016, 32(4): 771-778.
27.	Jiang C, Lou J, Qian W, et al. Impact of flexion versus extension of knee position on outcomes after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg, 2017, 137(2): 257-265.
28.	Stucinskas J, Tarasevicius S, Cebatorius A, et al. Conventional drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis: a prospective, randomised trial. Int Orthop, 2009, 33(5): 1275-1278.
29.	Faldini C, Traina F, De Fine M, et al. Post-operative limb position can influence blood loss and range of motion after total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 852-859.
30.	Mesa-Ramos F, Mesa-Ramos M, Maquieira-Canosa C, et al. Predictors for blood transfusion following total knee arthroplasty: a prospective randomised study. Acta Orthop Belg, 2008, 74(1): 83-89.
31.	Hewitt B, Shakespeare D. Flexion vs. extension: a comparison of post-operative total knee arthroplasty mobilisation regimes. Knee, 2001, 8(4): 305-309.
32.	Johnson DP. Infection after knee arthroplasty. Clinical studies of skin hypoxia and wound healing. Acta Orthop Scand Suppl, 1993, 252: 1-48.
33.	謝添, 馬彬彬, 李滎娟, 等. 加速康復外科在老年髖部骨折的研究現狀. 中國修復重建外科雜志, 2018, 32(8): 1038-1046.
34.	李佩佳, 高玉鐳, 王東辰, 等. 利伐沙班與低分子肝素在預防人工全膝關節置換術后深靜脈血栓形成的分析. 中國矯形外科雜志, 2012, 20(11): 998-1000.
35.	樊書新. 低分子肝素預防膝關節置換術后下肢深靜脈血栓 56 例療效觀察. 中國現代藥物應用, 2013, 7(24): 95-96.
36.	張德洪, 許建中. 人工膝關節置換術后感染應用關節鏡治療的臨床分析. 河南外科學雜志, 2014, 20(4): 44-45.
37.	Antinolfi P, Innocenti B, Caraffa A, et al. Post-operative blood loss in total knee arthroplasty: knee flexion versus pharmacological techniques. Knee Surg Sports Traumatol Arthrosc, 2014, 22(11): 2756-2762.
38.	張少云, 肖聰, 裴福興. 氨甲環酸在創傷骨科手術中應用的研究進展. 中國修復重建外科雜志, 2019, 33(11): 1457-1461.
39.	張選奮, 秦永紅, 魯開化, 等. 更新皮膚傷口診療理念, 建立愈合質量分級, 提高診療水平. 中國修復重建外科雜志, 2018, 32(8): 1088-1090.

1. Losina E, Thornhill TS, Rome BN, et al. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg (Am), 2012, 94(3): 201-207.
2. Weinstein AM, Rome BN, Reichmann WM, et al. Estimating the burden of total knee replacement in the United States. J Bone Joint Surg (Am), 2013, 95(5): 385-392.
3. Carson JL, Stanworth SJ, Roubinian N, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev, 2016, 10: CD002042.
4. Madjdpour C, Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth, 2005, 95(1): 33-42.
5. Raut S, Mertes SC, Muniz-Terrera G, et al. Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75. Int Orthop, 2012, 36(8): 1601-1608.
6. Voorn VM, Marang-van de Mheen PJ, So-Osman C, et al. Designing a strategy to implement cost-effective blood transfusion management in elective hip and knee arthroplasties: a study protocol. Implement Sci, 2012, 7: 58.
7. Li B, Wang G, Wang Y, et al. Effect of two limb positions on venous hemodynamics and hidden blood loss following total knee arthroplasty. J Knee Surg, 2017, 30(1): 70-74.
8. Li B, Wen Y, Wu H, et al. The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop, 2009, 33(5): 1263-1268.
9. Zeng Y, Si H, Li C, et al. Effect of knee flexion position and combined application of tranexamic acid on blood loss following primary total knee arthroplasty: a prospective randomized controlled trial. Int Orthop, 2018, 42(3): 529-535.
10. Ma T, Khan RJ, Carey Smith R, et al. Effect of flexion/extension splintage post total knee arthroplasty on blood loss and range of motion—a randomised controlled trial. Knee, 2008, 15(1): 15-19.
11. Wu Y, Zeng Y, Li C, et al. The effect of post-operative limb positioning on blood loss and early outcomes after primary total knee arthroplasty: a randomized controlled trial. Int Orthop, 2019, 43(9): 2083-2091.
12. De Fine M, Traina F, Giavaresi G, et al. Effect of different postoperative flexion regimes on the outcomes of total knee arthroplasty: randomized controlled trial. Knee Surg Sports Traumatol Arthrosc, 2017, 25(9): 2972-2977.
13. Motififard M, Heidari M, Nemati A. No difference between wound closure in extension or flexion for range of motion following total knee arthroplasty: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 74-78.
14. ?ükür E, ?ztürkmen Y, Akman YE, et al. The effect of tourniquet and knee position during wound closure after total knee arthroplasty on early recovery of range of motion: a prospective, randomized study. Arch Orthop Trauma Surg, 2016, 136(12): 1773-1780.
15. 王海霞. 全膝關節置換術后不同下肢體位對患肢康復的影響. 中國實用醫藥, 2016, 11(14): 87-88.
16. Yang Y, Yong-Ming L, Pei-jian D, et al. Leg position influences early blood loss and functional recovery following total knee arthroplasty: A randomized study. Int J Surg, 2015, 23(Pt A): 82-86.
17. Liu J, Li YM, Cao JG, et al. Effects of knee position on blood loss following total knee arthroplasty: a randomized, controlled study. J Orthop Surg Res, 2015, 10: 69.
18. K?mürcü E, Yüksel HY, Ersoz M, et al. Effect of surgical closing in total knee arthroplasty at flexion or extension: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc, 2014, 22(12): 3067-3073.
19. Napier RJ, Bennett D, McConway J, et al. The influence of immediate knee flexion on blood loss and other parameters following total knee replacement. Bone Joint J, 2014, 96-B(2): 201-209.
20. Panni AS, Cerciello S, Vasso M, et al. Knee flexion after total knee arthroplasty reduces blood loss. Knee Surg Sports Traumatol Arthrosc, 2014, 22(8): 1859-1864.
21. Li B, Wen Y, Liu D, et al. The effect of knee position on blood loss and range of motion following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2012, 20(3): 594-599.
22. 王思群, 黃鋼勇, 夏軍, 等. 全膝關節置換術后膝關節位置對術后失血的影響. 中華關節外科雜志 (電子版), 2011, 5(2): 160-164.
23. Ong SM, Taylor GJ. Can knee position save blood following total knee replacement? Knee, 2003, 10(1): 81-85.
24. Wang HY, Yu GS, Li JH, et al. An updated meta-analysis evaluating limb management after total knee arthroplasty-what is the optimal method? J Orthop Surg Res, 2019, 14(1): 97.
25. Wu Y, Yang T, Zeng Y, et al. 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. Int J Surg, 2017, 37: 15-23.
26. Fu X, Tian P, Li ZJ, et al. Postoperative leg position following total knee arthroplasty influences blood loss and range of motion: a meta-analysis of randomized controlled trials. Curr Med Res Opin, 2016, 32(4): 771-778.
27. Jiang C, Lou J, Qian W, et al. Impact of flexion versus extension of knee position on outcomes after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg, 2017, 137(2): 257-265.
28. Stucinskas J, Tarasevicius S, Cebatorius A, et al. Conventional drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis: a prospective, randomised trial. Int Orthop, 2009, 33(5): 1275-1278.
29. Faldini C, Traina F, De Fine M, et al. Post-operative limb position can influence blood loss and range of motion after total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 852-859.
30. Mesa-Ramos F, Mesa-Ramos M, Maquieira-Canosa C, et al. Predictors for blood transfusion following total knee arthroplasty: a prospective randomised study. Acta Orthop Belg, 2008, 74(1): 83-89.
31. Hewitt B, Shakespeare D. Flexion vs. extension: a comparison of post-operative total knee arthroplasty mobilisation regimes. Knee, 2001, 8(4): 305-309.
32. Johnson DP. Infection after knee arthroplasty. Clinical studies of skin hypoxia and wound healing. Acta Orthop Scand Suppl, 1993, 252: 1-48.
33. 謝添, 馬彬彬, 李滎娟, 等. 加速康復外科在老年髖部骨折的研究現狀. 中國修復重建外科雜志, 2018, 32(8): 1038-1046.
34. 李佩佳, 高玉鐳, 王東辰, 等. 利伐沙班與低分子肝素在預防人工全膝關節置換術后深靜脈血栓形成的分析. 中國矯形外科雜志, 2012, 20(11): 998-1000.
35. 樊書新. 低分子肝素預防膝關節置換術后下肢深靜脈血栓 56 例療效觀察. 中國現代藥物應用, 2013, 7(24): 95-96.
36. 張德洪, 許建中. 人工膝關節置換術后感染應用關節鏡治療的臨床分析. 河南外科學雜志, 2014, 20(4): 44-45.
37. Antinolfi P, Innocenti B, Caraffa A, et al. Post-operative blood loss in total knee arthroplasty: knee flexion versus pharmacological techniques. Knee Surg Sports Traumatol Arthrosc, 2014, 22(11): 2756-2762.
38. 張少云, 肖聰, 裴福興. 氨甲環酸在創傷骨科手術中應用的研究進展. 中國修復重建外科雜志, 2019, 33(11): 1457-1461.
39. 張選奮, 秦永紅, 魯開化, 等. 更新皮膚傷口診療理念, 建立愈合質量分級, 提高診療水平. 中國修復重建外科雜志, 2018, 32(8): 1088-1090.

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