“Pain is lower without a tourniquet, and non-tourniquet patients have better ROM [range of motion], ” says Aaron Rosenberg. “Hold up, ” says Steve MacDonald. “Do you really want to increase OR time and cost when there is no evidence to support the supposed downsides of using a tourniquet?”
This week’s Orthopaedic Crossfire® debate is “Tourniquet-less TKA: Let it Bleed.” For the proposition is Aaron G. Rosenberg, M.D. from Rush University Medical Center; against the proposition is Steven J. MacDonald, M.D. from the University of Western Ontario. Moderating is John J. Callaghan, M.D. from the University of Iowa.
Dr. Rosenberg: “We’re all trying to get to an operative experience that will results in a pain-free, fully functional knee. We have recently had improvements in peri-operative analgesia and rehab techniques, as well as certain biomechanical things to improve alignment and component design. We’ve also used closure in flexion and cryotherapy. And we’ve been focusing on the consistency that comes from reducing outliers and complications. Avoiding the tourniquet helps you accomplish all of these things.”
“First of all, it allows you to get the bleeding vessels as they come up, as opposed to obliterating them with the tourniquet and then ignoring them when the tourniquet comes down…allowing the blood to accumulate in the knee. Several studies have looked at tourniquet versus no tourniquet TKA [total knee arthroplasty], and almost all show a benefit. In 1997 there was a study in the Journal of Arthroplasty showing less thigh pain postop; in 2001 the Canadian Journal of Surgery had a study showing less overall blood loss and a trend toward fewer complications. A 2009 article in the Journal of Thrombolysis showed reduced local thrombogenic/fibrinolytic activity; it also found that the tourniquet release, after being up for a period of time, causes systemic activity. Finally, a 1998 study in Anesthesia and Analgesia revealed fewer DVTs [deep vein thrombosis].”
“The biggest concern has been blood loss. A meta-analysis from 2011 (Tai et al., Knee Surgery, Sports Traumatology, Arthroscopy) compared tourniquet to tourniquet-less and found that the total measure of blood loss favored the use of a tourniquet. Many of the other measures show no significant difference between the two…or a slight favoring of the tourniquet (but primarily only for intraoperative blood loss).”
“A 2010 meta-analysis (Smith et al., Knee) involved 15 studies and 1, 040 TKRs [total knee replacement]. The researchers found that no tourniquet use led to greater intraoperative blood loss, but there was no difference in total blood loss or transfusion rate, or any other measure assessed. And there was a trend to more complications with a tourniquet.”
“In 2013 Li et al. published a study in the European Journal of Orthopedic Surgery and Traumatology comparing TKA with and without a tourniquet. It involved 15 studies and 804 patients; there was no significant difference in calculated and measured total blood loss. Use of a tourniquet decreased intraoperative blood loss, but increased postoperative blood loss. My contention is that this blood frequently ends up in the knee, causing hemarthrosis and a reduced rate of return of flexion. There was no significant difference in operative time.”
“We now have several modalities available to us to help reduce perioperative blood loss. Tranexamic acid is probably the most widely studied in TKA, and it seems to be safe and effective. Also, there is a device by Medtronic (for whom I am a consultant) that uses bipolar radio frequency and saline, and shrinks the blood vessel collagen in the soft tissue and bone.”
“In a study published in 2012 (Ledin et al., Acta Orthopaedica) the researchers were looking to see whether or not tourniquet use improved fixation in patients with cemented knees. They randomized 50 patients to TKA with or without a tourniquet, and they used RSA (radiostereometric analysis) at regular intervals to measure fixation quality. They found no difference in motion of the components with RSA, and total bleeding at day four was slightly less in the tourniquet patients. However, pain was lower in the non-tourniquet group, and the non-tourniquet group had better ROM at two years (11 degrees greater). So consider going without a tourniquet…get the bleeders as you go. Use adjunctive means to reduce blood loss, avoid hemarthrosis, thigh pain, and other deleterious sequelae.”
Dr. MacDonald: “I have performed TKAs without tourniquets; there are pros and cons. There are a few randomized clinical trials (RCTs), many opinion pieces…but there is no registry data.”
“There can be no argument that a tourniquet reduces intraoperative blood loss. The 2010 meta-analysis mentioned by Aaron showed significantly greater intraoperative blood loss without a tourniquet. However, overall blood loss—intraoperative and postoperative—was not different between tourniquet and tourniquet-less groups. So the question becomes, ‘Do you want it in your field, or later, when you’re finished?’”
“Several studies do show decreased blood loss. In an RCT of 72 patients, the tourniquet group showed much less overall blood loss than those who didn’t have a tourniquet. But there is that short, transient postoperative pain that some people get in their thigh.”
“So if you’re going to use a tourniquet, how much of the procedure should you use it for? An RCT published in 2012 in the ANZ Journal of Surgery recommended—as I do—that if you’re using a tourniquet, use it for the whole procedure.”
“It’s a given that we want a dry bone surface for cementing. If you don’t have that there is a potential for increased risk of late loosening. There are techniques around that (to get a dry bone surface): meticulous hemostasis, pulsatile lavage, and filtered carbon dioxide.”
“But they all come with costs: dollars and time. A 2010 study in the Journal of Bone and Joint Surgery (Willis-Owen, et al.) with 3, 500 patients found a direct correlation between OR time and infection rate in TKA. This paper concluded that ‘steps to minimize intraoperative delay should be instigated, ’ and that ‘care should be exercised when introducing measures which prolong the duration of joint replacement.’ Be cautious in telling anyone to do something that’s going to increase your OR time.”
“As for the proposed downsides to a tourniquet, they’re either basic science theories or are rare or short term. One thing you hear all the time is ‘vessel wall damage leading to increased DVT.’ Is there a single clinical paper supporting this? No! Fukuda, et al. conducted a study involving tourniquet versus tourniquet-less (Archives of Orthopaedic and Trauma, 2007) where they gave all patients ultrasounds pre and postop. They found no difference in the incidence of DVT between these groups.”
“What about increase in wound healing disturbances? There is no evidence of that. Delay in muscle function recovery? No evidence of that. As for nerve damage, I think everyone who has done knees or used tourniquets for a long time will see transient nerve damage. I don’t think they’re permanent.”
“So don’t use a tourniquet if: you are concerned about the theoretical risks, you have alternatives to a dry field, if they are cost neutral, you don’t increase the OR time, and you don’t need published data on long term results.”
Moderator Callaghan: “Aaron, after that diatribe, do you have any other rebuttals?”
Dr. Rosenberg: “We use a tourniquet because it provides us with a bloodless field and makes the operation easier to perform in some respects. There are areas where that is vitally important, such as upper extremity surgery and flexor tendon repair in the hand. In the knee, where the landmarks are much larger, the amount of bleeding that one encounters isn’t sufficient to warrant the downside effects. And there are the occasional findings that you get in someone who has a swollen thigh or a postop decrease in ROM because of the effect of the tourniquet. Also, most of us have gone to not getting the bleeders as you go, letting the bleeding occur after we’ve closed the knee…and we end up with more blood in the knee than we’d like. By getting the bleeders and being meticulous in your approach, the morning after surgery when you remove the compressive bandage and begin ROM, I find the knees to be flatter, less full of fluid. The thigh is much softer and more amenable to the first day of physical therapy. Occasionally you need to do a TKA without a tourniquet; as you get more experienced with this it become much easier.”
Moderator Callaghan: “Steve, anything else?”
Dr. MacDonald: “Use a tourniquet.”
Moderator Callaghan: “Aaron, sometimes people say, ‘I don’t use a tourniquet, but I put it up when I’m cementing, etc.’”
Dr. Rosenberg: “I generally put the tourniquet up during the cementing process. So I will almost always put the tourniquet up unless the patient is a vasculopath. Also, it does allow you to see when you’ve got a significant lateral geniculate vessel should you encounter a significant trauma. Having the tourniquet in place is useful in case you have a vascular accident of significance. Some patients have a very dry field and we don’t need to put the tourniquet up to cement the knees; in cementless knees I don’t think it matters very much. ”
Moderator Callaghan: “Aaron, you and I are a decade older than Steve, so seeing bleeders is a bit more difficult for you and I. The other point is, if it’s the vasculopath or the person that you don’t put the tourniquet up for, do you do any preparation on the bone?”
Dr. Rosenberg: “The one thing that I haven’t used to clean the bone is the CarboJet; however, I’m very meticulous in my preparation of the bone—regardless of whether or not I use a tourniquet. I’m also meticulous about injecting the cement, and if I don’t get a good injection then I pressurize it with my thumb over the entire surface of the femur and the tibia so that it has a stippled appearance.”
Moderator Callaghan: “Steve, is there a tourniquet time that you get more concerned about?”
Dr. MacDonald: “I use tourniquets for my revisions as well…then it’s a bit more of a timing issue. I think, ‘Am I going to be able to get the whole revision done and cemented in place by the 120 minutes?’ Sometimes we’ll let it down for a period of time, but I want it up when I cement in a revision. What I don’t know is what the pressure should be. I put it up to 300 (350 if they are obese). But there is probably an ideal pressure, and it may be quite a bit lower than 300…that may mitigate the downsides.”
Dr. Rosenberg: “I think that’s true. It’s shocking that so many of my colleagues have that tourniquet up to 300/350. I generally try to pick 100mm of mercury above the mean arterial pressure.”
Dr. MacDonald: “Some complications—like thigh pain—are related to time.”
Moderator Callaghan: “If you let down a tourniquet on a bad revision, how long do you have to keep it down?”
Dr. MacDonald: “There’s no data on that, but I do a minimum of 30 minutes.”
Moderator Callaghan: “Thanks, guys.”
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What studies was Dr. MacDonald citing?