Efficacy of Modified Robert Jones Bandages on Reducing Invisible Blood Loss After Total Knee Arthroplasty: A Randomized Controlled Trial

In preoperative period, all eligible participants are admitted to the hospital for undergoing TKA. The detailed protocol, including how to rate visual analog pain score, times to take the blood for checking hematocrit levels, criteria for blood transfusion, time to measure the knee and thigh circumferences and plan of ambulation program, is informed again. The routine preoperative preparation is done. The participant is asked for answering preoperative Oxford Knee Score questionnaire. Participants' baseline characteristics are also recorded.

During intraoperative period, all participants receive the same anesthetic method (spinal anesthesia without morphine and peripheral nerve block). Two experienced surgeons (CK and NR) perform all procedure with the same surgical technique. A 750 mg intravenous tranexamic acid is administrated before inflating tourniquet and 3 hours after the operation. A tourniquet pressure of 300 mmHg is used and inflated before skin incision. Pre-incisional local injection with 10 ml of 1% lidocaine with adrenaline is done. A mini-medial parapatellar approach is performed. Cemented TKA prostheses (Nexgen LPS-Flex, Zimmer, Warsaw, Indiana) are implanted in all participants without patellar resurfacing. Periarticular analgesic injection is done with 20 ml of 0.5% bupivacaine, 20 ml of normal saline, 30 mg of ketorolac and 1 ml of 1% lidocaine with adrenaline. A number-10-gauge drain is placed intra-articularly and connected to the Ultravak pressure drainage bottle (Poly Medicure Limited, India). Extensor mechanisms are repaired and the wound closure is performed in the routine fashion.

At the end of operation, the randomized sequence is opened by a scrub nurse. Then, the participants are randomly assigned into two groups; Group 1 or MRJB group and Group 2 or non-compressive dressing (NCD) group. A tourniquet pressure is deflated after the dressing is applied.

In postoperative period, MRJB is left in place for 24 hours and then changed to NCD. All participants obtain the three-hour interval drain clamping protocol. After tourniquet release, the drain is clamped for three hours, released for three hours, re-clamped for three hours, and then the clamp is run continuously. Mechanical prophylaxis of deep vein thrombosis by ankle pumping exercise and ambulation on the bed is started as soon as possible. After 24 hours postoperatively, range of motion exercise and out-of-bed ambulation program are started. Ice packs are placed around the knee for at least 8 hours per day. The drain is removed at 48 hours after operation.

For operational definition, MRJB is defined as a three-layers of thick cotton wool and two-layers of elastic bandages. The wool layers are put on firmly and overlapped the previous one by half at each turn. The elastic layers were pulled snugly with more tension distally than proximally. Before wrapping in each turn, the elastic bandage was stretched approximately 2 and 1.5 inches at below and above tibial tuberosity level, respectively. The whole bandage attains a thickness of about two inches and extends above the ankle joint to six inches above the knee joint. Before applying this bandage, the sterile gauze pads were placed over the wound and followed by WebrilTM padding (Covidien, Mansfield, MA, US). While NCD is made by placing the sterile gauze pads over the wound and covering with the hypoallergenic self-adhesive, non-woven fabric tape.