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Large Joints Feature

Source: Wikimedia Commons and Wellcome Images

TKA: Time to Rethink Tourniquet Use

Elizabeth Hofheinz, M.P.H., M.Ed. • Tue, August 29th, 2017

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Is tourniquet use during total knee arthroplasty (TKA) de riguer? Time to re-think that, says new research.

The study, “Use of a Tourniquet in Total Knee Arthroplasty Causes a Paradoxical Increase in Total Blood Loss,”  appeared in the August 16, 2017 edition of The Journal of Bone and Joint Surgery.

Harold Rees, M.D., co-author on the study and assistant professor of orthopedic surgery at Loyola University School of Medicine in Maywood, Illinois, tells OTW, “There are benefits to performing total knee arthroplasty without a tourniquet, including better pain relief, lower rates of venous thromboembolism, and less swelling after surgery. The main reason surgeons use a tourniquet for knee arthroplasty is to decrease blood loss, but we noticed that blood loss did not seem to be different with or without the tourniquet.”

“Also, it made sense that intravenous medications like tranexamic acid could not reach the surgical site with the tourniquet inflated, so it was possible that there could be more blood loss because that medication would not work properly. We decided to look at this topic because if there actually was more blood loss with the tourniquet inflated, then that would mean that there is little benefit to using one, and it would make sense to eliminate it altogether.”

“We changed our protocols here at Loyola during the study period, from using a tourniquet without tranexamic acid, to using a tourniquet with tranexamic acid, and then finally to using tranexamic acid with no tourniquet. Subsequently we changed our routine anticoagulation protocol from warfarin to aspirin, so the patient cohort had three groups that were of sufficient size to make good comparisons, which is unusual for a retrospective study.”

The authors wrote, “A retrospective cohort study of 132 patients in three groups was performed. The first group underwent total knee arthroplasty with limited tourniquet use only during cementing, the second group had the same protocol but with tranexamic acid administered, and the third group had tranexamic acid but no tourniquet used.”

“We found that using a tourniquet without tranexamic acid in total knee arthroplasty showed the largest total blood loss, followed by a tourniquet with tranexamic acid, and the lowest blood loss was in patients who had tranexamic acid but no tourniquet used. This result was the opposite of what one would expect from tourniquet use.”

“In the current environment of alternative payment models, it is important for surgeons to decrease cost while improving patient care. Eliminating tourniquet use in total knee arthroplasty can save money by decreasing undesirable postoperative problems and reducing material costs.”

“Tourniquet use in total knee arthroplasty may not have the desired benefits, and may actually be detrimental to a good outcome after surgery. Surgeons should consider eliminating routine use of tourniquets for this surgery.”

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