This week’s Orthopaedic Crossfire® debate was part of the 35th Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Tourniquetless TKA: A Miraculous Conversion.” For is Jose A. Rodriguez, M.D., Hospital for Special Surgery, New York, New York. Opposing is Robert E. Booth, Jr., M.D., Jefferson Health 3B Orthopaedics, Philadelphia, Pennsylvania. Moderating is Paul F. Lachiewicz, M.D., Duke University Medical Center, Durham, North Carolina.
Dr. Rodriguez: Miraculous! And yet, reluctant. I’m here to talk to you about how I got to believe what I believe.
So, why do we use a tourniquet? Because it works. It’s gives you a nice, clean surgical field. Less blood loss and reproducible cement technique. And this has been my practice for 20 years.
There are downsides. Tissue ischemia, direct pressure damage, or the embolic load that can occur with tourniquet release.
Five years into practice, my mentor Dr. Chitranjan Ranawat, started believing that tourniquets had issues. He believed in fewer tourniquets. He used tourniquets only for cementing. I resisted. This is one time that I resisted to my discredit.
After a couple of years, Dr. Amar Ranawat and I looked at our respective populations. His group comprised of only tourniquet during cementing. Mine being tourniquets from the beginning to the point when the dressing is on.
My group demonstrated that the maximum drop in hemoglobin and hematocrit was slightly higher than in the limited tourniquet groups. I felt justified. I’m preserving blood. That makes sense. Now deep in the data you also found that there were non-statistically significant increases in stiffness requiring manipulation and pulmonary embolism in my group. But that was deep in the data and before TXA [tranexamic acid], which is considered by many the modern day tourniquet.
Then there was a lovely 59-year-old female skier that I took care of two years ago. Granted, 79 minutes is a lot of tourniquet time. My opponent can do 3 knees in that time. But I obsessed trying to get the mechanics of this case right and then the mechanics were beautiful. She got great motion, but she had pain, weakness and extensor lag. After workup, we found that she had an EMG-demonstrated femoral nerve damage, most likely from the tourniquet.
And then I came to this conference and stood at this podium while Mike Meneghini described a retrospective study of 200 cases, tourniquet versus no tourniquet, demonstrating definitely marked reduction in pain and opioid use in women with no tourniquet compared to tourniquet (Kheir, et al., JOA, 2018). And given that scenario, that setting, was very meaningful to me. It made me look to figure out what the literature actually says.
In a randomized controlled trial of 70 patients—tourniquet versus no tourniquet—all around better KOOS [Knee Injury and Osteoarthritis Outcome Score] scores and range of motion at 8 weeks in the non-tourniquet group (Ejaz, Acta Orthopaedica, 2014).
