A meta-analysis by Alcelik, et al. (J Arthroplasty 2012) looked at outcomes—minor complications were more common with a tourniquet, but there was no difference for operative time, DVT / PE and major complications. The total and intraoperative blood loss was less with the tourniquet.
Another meta-analysis looking at 13 papers (Yi, et al., AOTS 2014). Significant decrease in the operative time, intraoperative blood loss and total blood loss, but a significant increase in postoperative blood loss. No significant increase in DVT or infection.
Another one (Zhang, et al., J Orthop Surg Res 2014). Significant reduction in intraoperative blood loss and operative time. No reduction in transfusions. Range of motion decreased; thrombotic events increased. And minor complications increased.
There’s no free lunch. As we learned from Doug Dennis (CORR 2015), there’s decrease in surgery time, lower intraoperative blood loss, but a higher total blood loss. Maybe DVT. And slightly lower extremity strength out to about 3 months.
I think the other thing is the timing of release. So, how long do you leave it up and when do you let it down? If you let it down earlier, there was a significant increase in total blood loss and drop in hemoglobin. But reoperations due to postoperative complications were much less in the earlier release versus the late release (Rama, et al., JBJS 2007).
Another reason to release the tourniquet after cementation is to assess patellofemoral tracking and I’ve published on this topic and found a 69% reduction in indication for lateral retinacular release.
My take-home message to you is that I use a tourniquet because it does help me get a better exposure. It does help me visualize the bony landmarks. It does help me implant the device correctly.
It facilitates my focus on the proper positioning of components and it facilitates the cementing technique. And, I think at the end of the day, none of those RCTs really gave me any information about timing. So, if you can do your operation efficiently, I believe use of the tourniquet is definitely a thing to do.
Moderator Thornhill: Okay, let me ask the audience. How many people routinely use a tourniquet when they do a total knee? About 220. How many of those who use a tourniquet now think that they might consider NOT using a tourniquet after what you’ve heard? So that’s more…. That’s very interesting.
Adolph, you said something that is quite correct. It all depends on how much and how long. My question is “How much and how long, and how much time in between?”
Dr. Lombardi: You don’t need to on every patient put that tourniquet up at 350-400. Look at the size of the leg; look at the pressure. Some devices are smart, and they can actually tell you what pressure you need to put it at. The literature says that you should leave the tourniquet up for more than 2 hours. But, I don’t take 2 hours to do a total knee, so our tourniquet times are pretty short.
Moderator Thornhill: How much pressure in an average person? 250? 300? Does systolic pressure make any difference?
Dr. Lombardi: Yeah, I generally do about 250-300 in an average limb and when I get the real bulky limb we go up to 375-400.
Moderator Thornhill: So let’s say you’ve got somebody with Mönckeberg sclerosis—the really sort of calcified vessel—and you put it up to 400…
Dr. Lombardi: I don’t put a tourniquet on that patient. If they have any peripheral vascular disease, if there’s any indication from my internist that maybe we shouldn’t use a tourniquet, we don’t use a tourniquet for that patient. And it’s a miserable day for me.
Moderator Thornhill: Robert, blood loss.
Dr. Barrack: I may have a skewed view because I stopped using a tourniquet the same time we started using TXA [tranexamic acid] but that’s been 5 years. And I was pleasantly surprised that after the first 5 minutes of the case, when you flex the knee and start your bone cut…all the residents and fellows are amazed by how little blood they’re looking at.
Moderator Thornhill: I think if you look at the whole episode, it’s been shown that overall blood loss may occur at different times, but the overall blood loss is roughly the same. Is that true, Adolph?
Dr. Lombardi: That’s true. I think the literature is pretty clear on that. The overall blood loss is about the same whether you use a tourniquet or not. To me …I’ve tried it and it’s a bloody mess.
Moderator Thornhill: I generally have the tourniquet put up for the first 5 minutes of opening and then let it down. I am not sure I get a hyperemia, but in flexion it doesn’t seem to bleed. I usually use it for cementing, but not always. When I do a uni, since I extend the knee and flex the knee a fair amount, I use a tourniquet.
Great debate is one that generates a lot of questions. I want to thank everyone, the audience for being here.
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