Truth is almost everybody uses a tourniquet at some point. Some, like me, for the whole case. Some just for the closure. Some for cementing. Some for cementing and closure.
“Operating without a tourniquet is like fixing a watch inside an inkwell,” is an old saying from one of the founding fathers of orthopedics (Sterling Bunnell, M.D.).
However, everything Jose said is true. That there are all these minor annoying problems. But if you look at the studies he quoted, most of them are 3-month follow-up. Everything is instantaneous in our world now.
We usually go back to the meta-analysis of which there are three salient ones on this, all of which showed that time was no different for Alcelik, et al.; lower with a tourniquet for Yi, et al.; and lower with a tourniquet for Zhang, et al. And it’s that time, as well as the blood loss. Blood loss, I think, Jose would conclude is a wash.
I’m not a fan of meta-analysis. They’re usually done by somebody who’s got more time to write than operate and they mix all sorts of the literature in ways that are not necessarily enlightening. I believe in experience-based medicine.
All those complications you heard about are related to the tourniquet time. We know, from that big book that Dr. Parvizi put in your bag that infection and DVT are linearly related to the length of the surgery. So, if you’re doing an hour and a half total knee, you’re going to have 3 times the infection and DVT rate. For total knee revisions where there’s a lot of blood, most of us use a tourniquet for up to 2 hours without thinking about it. And what I never understand is if you do simultaneous bilateral knees, the second side always bleeds more. There’s something going on there we don’t understand.
For me it’s about time, predictability and the convenience of doing the surgery.
Where’s the surgeon satisfaction factor? We talk now about all these patient-related scores. I want my own Press Gainey score. I think the inmates are running the prison frankly. I want something that makes me comfortable, happy and predictable so I don’t have to worry.
I’ve known since I was a resident as Nas Eftekhar (CORR, 1975) showed with hips, that a hip socket filled with saline stuck better than one that had blood in it. I’ve believed that all my life. I’ve had a lifelong interest in picking patients who were good candidates for tourniquets because there are some issues there. Anybody with calcifications, even of the minor variety, I think, should be out of it. Certainly, the Mönckeberg’s Sclerosis (Couri, et al., BMC Cardiovasc Disord, 2005) people are definitely not candidates. People with stents, bypasses should not get tourniquets. There’s no predictive test…the ankle brachial index is not helpful. Obesity often obviates the use of a tourniquet altogether. And the worst thing of all is slow surgery.
Two of the most recent studies, which are good studies, looking at tranexamic acid versus with or without tourniquets are with surgeons who did 70- or 80-minute total knees. That’s too long for a tourniquet.
The pressure should be above systolic, and you can take an empiric number and you’d better know that your hospitals don’t calibrate those tourniquets. They come in different lengths, but few people realize they come in different widths. The pressure of the tourniquet is related to its width, not its length. If you have a fat person, you need a wider tourniquet, otherwise you’re having to apply a lot more pressure and this is a bad situation.
The game changer has been tranexamic acid. We’ve used it intravenously. Did have a little bit of an increase in pulmonary embolism rate and went to oral, which has been fine. And now our hospital is cheaping out and trying to get us to use topical. I think the answer is still out on exactly what the best combination is of that group.
Bottomline is my staff hates tourniquetless procedures. They don’t like blood in their face, and frankly they feel about the same way I do about the visibility. That’s probably what is motivating me most.
Dr. Lachiewicz: I have some questions for both of you. Jose, so do you put a tourniquet on the limb just in case, or are you totally avoiding them?
Dr. Rodriguez: I put the tourniquet on just in case. However, I haven’t inflated one in about a year.
