Dr. Lachiewicz: Do you think the tourniquetless knee is viable if you don’t have a cooperative anesthesiologist?
Dr. Rodriguez: It is viable, just less reproducible.
Dr. Lachiewicz: One last question as many of us are irrigating now with either diluted betadine solution or some other types of solutions, how does that work with the tourniquetless total knee? Doesn’t that stuff wash out. Do you use that at HSS—diluted betadine?
Dr. Rodriguez: I do. The same way it works in a hip. I use them in a hip as well.
Dr. Lachiewicz: Bob, can you just reiterate for the audience the patients in which you would NOT use a tourniquet, where it’s contraindicated?
Dr. Booth: When they’re morbidly obese, especially in the thigh where the tourniquet might be. When they have calcifications. Possibly a stent. Those are the people I would avoid in general. There is no test.
Dr. Lachiewicz: Bob, what about tourniquet pressures? I know several of the residents that I work with always want to put the tourniquet up to 350 for a total knee. Do you have a parameter for that? Should it be 100 over the highest systolic? Is it 250?
Dr. Booth: Generally I use around 300. But I’m only using 20 minutes for a knee, so I don’t really feel too terrible about that. If they’re fatter, you have to put it up higher, but rather than getting the same tourniquet and raising the pressure, you really should look for those wide tourniquets. I think that’s the biggest issue in using a tourniquet properly.
Dr. Lachiewicz: Jose, I use the tourniquet except in the situations similar to those Bob has looked at it. A lot of the papers people present with the tourniquetless total knees are statistically significant, but are they really clinically important? Are you convinced that these patients are a lot better?
Dr. Rodriguez: You’re only as good as your last complication. And that one woman, where I really believe if I had not used the tourniquet, she would not have had the complications, haunts me. So, that has significantly affected how I view everything. You can do an excellent total knee without inflating the tourniquet. That’s the point.
Dr. Lachiewicz: Bob, can you recall serious complications which you feel were related to tourniquet use?
Dr. Booth: I’ve been sent two people who had femoral nerve palsies. In my own hands I’ve really not had problems with tourniquets since I learned to avoid those people we discussed. Your point is very well taken about which complications matter. I’m mindful of John Callaghan’s paper on simultaneous bilateral total knees where he had 15 complications that occurred and the conclusion was you should not do them simultaneously. When they took out everything accept DVT, infection and limb loss, the things that really mattered, suddenly it was better to do it simultaneously.
Dr. Lachiewicz: Thank you very much gentlemen. I hope this was helpful for the audience.
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