“No tourniquet! Get the bleeders as they come up, ” argues Aaron Rosenberg. Jay Parvizi counters, “With a tourniquet you get a bloodless field and better visualization. You can try to cauterize the vessels as they come up, but I don’t think you can cauterize bleeding from bone.”
This week’s Orthopaedic Crossfire® debate is “The Tourniquet-less TKA [total knee arthroplasty]: Let It Bleed.” For the proposition is Aaron G. Rosenberg, M.D. of Rush University Medical Center in Chicago; against the proposition is Javad Parvizi, M.D., F.R.C.S. from the Rothman Institute in Philadelphia. Moderating is Michael J. Dunbar, M.D., F.R.C.S.(C), Ph.D. from Dalhousie University in Halifax.
Dr. Rosenberg: “I was talking to Seth the other day when he said, ‘Hey Aaron, do you want to debate Jay Parvizi?’ You can imagine my response…$%##&*%. But, we are here to talk about improving results in total knee arthroplasty. Going without the tourniquet—or reducing tourniquet time—is one of the ways that we can improve our recovery curve.”
“We know that the tourniquet gives us better visualization because it eliminates blood from the field; it also allows for more rapid surgery. There was a recent analysis by Smith and Hing that looked at 16 outcome parameters and 15 studies comparing tourniquet and no tourniquet in a randomized fashion. The no tourniquet patients had greater intra-operative blood loss, but there was no difference for total blood loss, transfusion rate, or any of the other measures assessed. There was, however, a trend for more complications in patients with tourniquets.”
“A 2011 meta analysis by Tai, et al. looked at blood loss in several randomized studies. In total measured blood loss there was a slight favoring of the tourniquet, but there was one study with a huge outlier. As for calculated blood loss, it slightly favors no tourniquet; intraoperative blood loss does favor the use of the tourniquet. But postoperative blood loss favors no tourniquet.”
“There are other ways of minimizing blood loss during surgery that have become popular since those studies were done. They include the use of transexamic acid, an antifibrinolytic that has been extensively studied, has been shown to be safe, and that dramatically reduces blood loss. I like to use a bipolar sealing technology. If I can see the oozing areas and stop it then that means less blood in the knee postoperatively, as well as a dramatic reduction in the incidence of hemarthroses postoperatively.”
“There are several randomized studies that have shown less pain, less swelling, and earlier flexion achieved without the use of a tourniquet. So I believe in no tourniquet…get the bleeders as they come up. As you become more experienced with this your visualization is not inhibited. Your operative time is slightly lengthened, but what you get for that ‘price’ is a knee that is less swollen the day after surgery, and a significant decrease in the amount of postoperative intraarticular bleeding. And avoiding a tourniquet has shown not only less thigh pain, less overall bleeding, and a trend to fewer complications, but local thrombogenic and fibrinolytic activity is decreased because releasing the tourniquet causes a systemic rise in thromboembolic activity.”
“A paper from Sweden was just published in Acta Orthopaedica looking at 50 patients, randomized to TKA with or without a tourniquet. They were all cemented total knees and all had the same implants. They performed radiostereometric analysis (RSA) at regular intervals because they wanted to see if not using the tourniquet influenced cemented fixation. They measured pain, visual analog scores, morphine consumption, overt bleeding, transfusions, total bleeding as measured by hemoglobin dilution, and ROM [range of motion] at two years. They found no difference in the RSA maximal total point motion scores, so the quality of the fixation was identical. The total bleeding at day four only was slightly less in the tourniquet patients, but pain was lower in the non-tourniquet group. The ROM at two years was 11 degrees greater; that is an impressive increase in flexion given a relatively small change in technique.”
“To my debate partner, let’s agree to compromise, no matter how wrong you may be.”
Dr. Parvizi: “Aaron is one of the greatest scholars I know, and quite honestly ever since I knew that I would be debating him I’ve been taking my anti-anxiolytics. I usually take my formidable opponents out for a drink, feed them some tequila and try to get them arrested so they won’t make it to the podium. I tried that with Aaron, but unfortunately he still made his way here.”
“So why not use a tourniquet? Expense, vascular injury, potential for embolization, possible rhabdomyolysis, metabolic effects when you release it, and possibly issues with the extensor mechanism alignment. I use a tourniquet because I like a bloodless field. Some of these are revisions, complicated cases, and it provides better visualization. You can try to cauterize the vessels as they come up, but I don’t think you can cauterize bleeding from bone.”
“Lower blood loss has already been proven, but you should examine all of the studies. Even though there is one outlier every single study shows that blood loss is either on the line or favors tourniquet. As for intraoperative blood loss, there is a recent meta analysis (Alcelik, 2012) showing extremely good results in terms of blood loss and transfusion. There is shorter operative time when you use a tourniquet and I stress that operative time translates to numerous things during surgery: reduced bio burden, lower surgical site infections, efficiency in the OR.”
“Regarding operative time, just about every surgery with the exception of two favors tourniquet. Is there higher VTE [vein thrombosis embolism]? I’m not sure that this has been studied properly. One of the problems is that when we release the tourniquet there’s a lot of fat and marrow emboli that make their way to the lung. We have done a study showing that the majority of these emboli that are read by the radiologists as pulmonary emboli are actually fat and marrow emboli that are irrelevant and resolve with time.”
“Again, in the 2012 Alcelik study showing that possibly there is a slightly higher incidence of DVT [deep vein thrombosis] or pulmonary embolism. But these studies do not make a distinction between fat and marrow emboli and a true pulmonary embolism. And the more you look for it the more of it you are likely to see. I think it does lead to higher postoperative blood loss. I agree with Aaron in that once you release the tourniquet if you have not done a good cauterization during surgery you are likely to encounter a higher incidence of bleeding postoperatively. But that is for people who just cut through without any respect for the vessels and the capillaries and don’t cauterize them during surgery.”
“We published a study in 2001, and we have what we call a surgical APGAR score. The more bleeding you see the more stress the patient has to endure in the postoperative period. Transfusion rate has been shown to correlate with higher rates of surgical site infection. In a recent New England Journal of Medicine transfusion rate was shown to correlate with increased mortality. For every APGAR score going up you will see an associated decrease in outcome in terms of systemic. So there are more complications with bleeding and that’s because of the oxidative stress after surgery.”
“So for those of you who say, ‘Why use a tourniquet in TKA, ’ I say, ‘Why not?’”
Moderator Dunbar: “Aaron, you don’t ever use a tourniquet?”
Dr. Rosenberg: “There are cases where there is a lot of bone bleeding and that is the most difficult to stop. In those cases I put the tourniquet up. I do think that there is a consistent decrease in the amount of post-operative pain, swelling, and fewer hemarthroses. I don’t put the tourniquet on in cases where there are previous vascular surgery.”
Moderator Dunbar: “Jay, do you use a tourniquet on every case? Who would you not use it on?”
Dr. Parvizi: “Patients who have had previous vascular bypass, particularly in the lower extremity. In those patients I worry about embolizing the vessels. And in some patients applying a tourniquet is extremely difficult; in short people with massive thighs you get a venous type tourniquet and you don’t get the proper bleeding control.”
Dr. Rosenberg: “Jay and I agree on almost everything that we do, except for some technique-related areas. The principle is the most important thing. For me, the principle is to minimize the damage I do during the case. I have some partners who put the tourniquet up to very high levels, regardless of the patient’s thigh and blood pressure.”
Dr. Parvizi: “Great point. Some studies show it should be only 100 mm mercury about the systolic. You don’t need to crank it up to 400. Also, if you’re not using a tourniquet you can’t just go in slashing like a ninja and go all the way to the end of the procedure because that blood loss is extensive. You must control bleeding as you go along.”
Moderator Dunbar: “Aaron, are you aware of any papers showing a functional difference in the quadriceps after total knee, with or without a tourniquet.”
Dr. Rosenberg: “There are papers showing that there’s better quadriceps function without the tourniquet in the first few days postop. But I don’t think the first few days are important…not nearly as important as getting the knee in right, getting the balance correct, etc. This is why I think we’ve backed off on MIS. And, avoidance of the tourniquet does allow me to do one of the important things intraoperatively that I don’t get a chance to do, which is to get the bleeders.”
Moderator Dunbar: “Jay, do you let the tourniquet down at any point to check for bleeders?”
Dr. Parvizi: “No, unlike Aaron I try not to cut through main vessels. No, we don’t let the tourniquet down to check for bleeders—that is dangerous. You don’t use a tourniquet, then put it up and cement, and then let it down again…that never made sense to me. During cementation is when fat and marrow embolization happens, and the extent of that embolization is associated with increased oxidative stress.”
Moderator Dunbar: “I think the strongest data Aaron presented is the RSA data. Do you think that is a relevant finding?”
Dr. Parvizi: “It’s relevant and supports what I have been saying here.”
Moderator Dunbar: “The fact that the migration pattern is stable is interesting, but you need to see what the technique was.”
Dr. Rosenberg: “Regardless of the fixation issues they did have 11 degrees more flexion in those knees at two years.”
Moderator Dunbar: “Thank you both.”
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