What about thromboembolic complications? Two meta-analyses, both came out strongly in favor of not using a tourniquet in order to minimize embolic complications (Tai, et al,, Knee Surg Sports Traumatol Arthrosc, 2011; Zhang, et al., J Orthop Surg Res 2014).
A very interesting study by Guler, et al. (Knee Surg Sports Traumatol Arthrosc 2016)—74 patients that had quantitative MRIs of both thighs after unilateral total knee arthroplasty with or without a tourniquet. The researchers found that there was marked atrophy when a tourniquet was used. These authors concluded that you should really be careful when you use a tourniquet and to minimize use if you use it at all.
When you use a tourniquet, intraoperative assessment is compromised. Patella tracking, range of motion, ligament stability and it complicates IV drug use. If you look at all the randomized clinical trials, they favor not using a tourniquet. Occasionally they will say that the results are equal, but if there is a difference, it always favors going tourniquetless. Same with the meta-analyses.
The AAOS has released guidelines for surgical management of osteoarthritis and they state there is strong evidence, the highest level, 4 stars, of less pain when you don’t use a tourniquet.
Where did tourniquets come from? They were used in the battlefield in the Civil War. They probably saved thousands of lives. They were used for battlefield amputations. In the last decade, the U.S. Special Forces Command mandates the issuance of tourniquets to our combat forces. But for combat wounds and urgent vascular injury, the benefit of the dramatic tissue damage exceeds a risk, but for total knee arthroplasty it does not.
Dr. Lombardi:
As you heard, a tourniquet controls bleeding from amputations and it may actually save a life. I know the term was coined by a Frenchman—Jean Louis Petit—I had a French fellow who told me I should be saying “turnakey.”
Today, tourniquets are used about 15,000 times a day.
Some people don’t use a tourniquet. Others use the tourniquet only for the exposure. Robert uses the tourniquet for cementation. I like to release the tourniquet after I cement. And then we have people who release after closure.
But, they all use tourniquets.
We know exactly what we’re doing when we use tourniquets. It is part of the routine.
Position the patient, give them antibiotics, put the tourniquet on, figure out what pressure, prep, drape, time out and then do your surgery.
What are the advantages? Why do I use it?
It enhances my visibility. There is less blood while I’m cementing. Less intraoperative blood loss—and I agree with Robert that overall there’s no significant difference—total blood loss or transfusion. I do believe that tourniquets help me focus on exactly where I’m putting those components and making sure that I get proper alignment, and proper balance, etc.
We learned over 20 years ago less blood and fat, better interdigitation, better penetration, lavage and have a nice dry field for longer term survivorship.
There is a danger. If it’s used improperly and for too long or at too high of a pressure, we can see some neurological injury. Robert’s absolutely correct. There is a lot of literature on this and it might sway you to think that you shouldn’t use a tourniquet. There is a significant decrease in intraoperative blood loss; non-significant differences in total blood loss and transfusions and an increased trend towards wound hematomas, DVTs, and wound healing disorders.
