The Effect of Tourniquet Use in Total Knee Arthroplasty - PDF
21 Pages4738 Words190 Views
Added on 2019-11-20
The Effect of Tourniquet Use in Total Knee Arthroplasty - PDF
Added on 2019-11-20
ShareRelated Documents
Critical Review Critical ReviewCritical review of two articles evaluating the effect of tourniquet usage or limbpreconditioning in reducing pain after total knee arthroplasty1
Critical Review IntroductionPain is very common after a total knee arthroplasty (TKA), affecting at-least 20% of patientspost-operatively (Wylde, 2013, Hatten, 2016).Many studies have suggested that there is adirect relationship between post-operative pain management and post-operative recovery(McCartney & Nelligan, 2014). Post-operative management of pain after TKA is a massivechallenge for health-professionals as improper pain management can affect the earlyrehabilitation process and recovery, delay hospital discharge and might have a severe impacton patients’ functional outcomes. The administration of systemic-opioid or epidural analgesiacould increase side-effects, including hypotension and respiratory depression after TKA(Husted et al., 2011). Therefore, in the last few decades, alternative pain relief measures havebeen employed to promote pain relief, as well as to counteract the side-effects of the drugs(Kao et al., 2015). Two articles were selected in this study to critically evaluate theeffectiveness of tourniquet usage and/or limb preconditioning in minimizing post-operativepain after TKA. Literature searchThe literature was searched using MEDLINE (Ovid) and PubMed sources. The key wordsused in both sources were "Tourniquet usage” AND “Limb preconditioning” AND“Postoperative pain relief” AND “total knee arthroplasty” OR “replacement”. The literaturesearch was limited to those works published between 2011 and 2017 to obtain the current andappropriate studies. The articles selected were only those that referred to humans and thatwere published in the English language. The search was limited only to randomized-controlled trials (RCT), as it a true experimental design, which is superior to otherquantitative studies (Polit & Beck, 2016). Fifty-three articles were found that were related tothe search terms through the MEDLINE (Ovid) and PubMed searches, of which the best 10were selected (Appendix- C & D). From these, two suitable articles were scrutinized for2
Critical Review critical evaluation to establish and compare the best available evidence for the reduction ofpost-operative pain after TKA. As an abstract gives a clear and concise picture of the detailsof studies, the abstracts of various studies were considered and the most appropriate studieswere selected for comparison and critical appraisal (Polit & Beck, 2016).Critical appraisal involves determining whether an article is trustworthy, appropriate,adequate and relevant to a given context (Steen & Roberts, 2011). It helps to judge thepositive, and the negative parts, of a study (Merriam-Webster, 2015). This critical evaluationwill clearly analyse varied research elements and their applicability in healthcare practice topromote post-operative pain management in TKA patients. Varied research-critiquing tools,as the Consolidated Standards of Reporting Trials (CONSORT, 2010), Rochon’s guide, Polit& Beck’s tools (Greenhalgh, 2010) and the Jadad score, are available from which the CriticalAppraisal Skills Programme (CASP, 2010) was selected, as it is the most appropriate tool tocritique an RCT (Baker, 2014). Two articles were selected to discuss tourniquet usage or limbpreconditioning for reducing post-operative pain in patients after TKA. Article A:Wang, K et al. (2015). The effects of tourniquet use in total knee arthroplasty: a randomized,controlled trial: Knee Surgery, Sports, Traumatology, Arthroscopy. 25: 2849–2857Article B:Memtsoudis, S. G et al. (2013). Does Limb Preconditioning Reduce Pain After Total KneeArthroplasty? A Randomized, Double-blind Study: Clinical Orthopaedics and RelatedResearch. 472: 1467–1474. doi. 10.1007/s11999-013-3106-4Literature reviewA literature review is defined as a summary of research into and study of an area of interest,which is usually developed to formulate the study’s problem in context (Polit & Beck, 2016).3
Critical Review Both articles literature reviews are clear and concise (Houser, 2011). They are well-organised, with correct citations and both articles’ researchers have laid out the literaturereviews in a systematic, logical and sequential manner (Greenhalgh, 2010). They havediscussed the related studies in an unbiased way, particularly Article A, which even has manystudies that portray the disadvantages of using tourniquets. Moreover, the researchers haveclearly demonstrated their insight into their respective problems by providing an overview ofTKA along with the study’s subject (tourniquet use or limb pre-conditioning), their benefitsand adverse effects, an explanation of their technique and their motivation for the study. Theyhave provided relevant, suitable, appropriate and comprehensive studies (Polit & Beck,2016). Most of the studies took place over a period of 12 years (2001 to 2012); however, a fewstudies in both articles were too old to consider. Although older evidence is required togeneralise the results, it might create bias in understanding the concepts, as advancements inscience and technology occur almost every day (Tappen, 2010). Moreover, in Article A, theresearcher has concentrated more on the disadvantages of tourniquet-use and about its effectson controlling blood-loss. It might have been better if the researcher had included someevidence to discuss its advantages in reducing pain. Furthermore, in Article B, no studieswere quoted about the disadvantages of limb-preconditioning and it might have been better ifthey had been added. Both studies adequately provided a theoretical-framework by clearlystating their interventions (Polit, 2016). Finally, they gave their motivation behind conductingtheir studies, which is evidenced in their literature-review. Identification of Problem with formulation of research The researchers of both Articles have identified their problems clearly and have provided theproblem statements based on the Patient Problem, (or Population), Intervention, Comparisonor Control and Outcome (PICO) framework. According to Polit and Beck (2016), a research4
Critical Review problem is defined as a puzzling condition that could be investigated by a systematic inquiry(THS, 2015). In both researches, it is evident from the description that they are interested indetermining the effects of alternative measures (tourniquet use and limb preconditioning) toreduce post-operative pain after TKA surgery, rather than pharmacological measures, toavoid side effects. Both researchers have provided a clear and concise study-purpose toinvestigate the effect of tourniquet or limb-preconditioning measures in minimising post-operative pain. The research-purpose agrees with the research-problem, as well as with thetitle (Fink, 2013) and the researchers has given a detailed description of rationale for theirstudies. The mention in Article A regarding the lack of dissemination of previous tourniquetstudies that has motivated them to propose a cross-over trial in bilateral arthroplasty patients,is appropriate (Wang, 2015). Similarly, the description in Article B regarding the incidentalfindings of the effect on pain of pre-conditioning before inflating the tourniquet for TKA isalso appropriate (Memtsoudis et al., 2010). In Article B, the researcher has given a clear and achievable objective that relates to theresearch purpose (Moule & Goodman, 2013). Their aim is to evaluate the effect of limbpreconditioning upon post-operative pain during rest and exercise, the effect of painmedicines, systemic prothrombotic drugs with inflammatory marker levels and length ofhospital-stay with milestone achievements through physical therapy, which is based on theirobjective. However, in Article A, they have not stated their objective clearly (Wang, 2015). Itis understood from the hypothesis that their objective was to evaluate the effect of a short-duration tourniquet on post-operative pain after TKA. Article B has given a clear objectivewhen compared with Article A. A hypothesis is the predicted relationship between the dependent and independent variables(Polit & Beck, 2016). In both the articles, statistical hypotheses were formulated to direct thestudies. A hypothesis should clearly focus on, as well as concisely express, the objectives5
Critical Review (Moule & Goodman, 2013), which is evident in both studies. Article A has proposed 2hypotheses and Article B with 4 hypotheses, which were based on their objectives. Thestudies’ hypotheses, aims and questions logically follow on from the studies’ problems(Munhall, 2012). Research- MethodologyA study’s methodologyinvolves the systematic arrangement of the research elements tostructure a study, as well as to gather data and analyse it (Polit & Beck, 2016). A RCT wasemployed in both studies which is known as a true experimental design that is characterizedby a manipulation with intervention (in this case, either tourniquet-use or limbpreconditioning), a control group without intervention and randomization (assigningparticipants to both the control and experimental group on a random basis) (Tropical HealthSolutions (THS), 2015). It is a type of quantitative design that helps to draw directcomparison between two treatment methods. It assists in making causal inferences andprovides the strongest evidence of the intervention’s efficiency, as well as minimising bias(Yartsev, 2017). Blinding involves preventing the persons involved in a study from obtaining informationabout the participants, the treatment modality or the investigators to minimise potential bias(LoBiondo-Wood & Haber, 2014). In Article A, the observer was blinded, whereas, in ArticleB, both the patients and the assessors were blinded (double-blinding). Moreover, Article Aused a crossover design, which involves exposing one group of participants with more thanone condition in a randomized order, through which the participants will serve as their owncontrols (Houser,2011). This helps to ensure an increased likelihood of equivalence amongparticipants being exposed to varied treatments, which was not practiced in Article B.Providing 2 different durations for tourniquet usage, along with washout timing for threemonths between interventions, and making the participants serve as their own control will6
End of preview
Want to access all the pages? Upload your documents or become a member.
Related Documents
Critical Appraisal of Intravenous and Intra-Articular Tranexamic Acid in Total Knee Arthroplastylg...
|5
|890
|98
Endoscopic Vein Harvesting for Coronary Bypass Graftinglg...
|20
|4371
|284
Systematic Literature Review Critical Appraisallg...
|7
|1498
|20
Evidence-Based Practice for Repositioning in Pressure Ulcer Preventionlg...
|10
|3287
|70
Pressure Ulcers in Diabeteslg...
|8
|1069
|420
Effectiveness of Interventions to Prevent MRSA Infection in Hospitalslg...
|17
|4823
|27