Next up was Amar S. Ranawat, M.D., Professor of Clinical Orthopaedic Surgery, Weill Cornell Medical College Attending Surgeon, Hospital for Special Surgery, New York, New York, who argued “I Know Why You Are Afraid, Don’t Be, No Need For The Tourniquet, Tourniquets are Dangerous.”
Dr. Ranawat: While tourniquets work, at times they are dangerous. Ideally, surgeons would know how to do surgery without them.
My opponent just said that a tourniquet “minimizes blood loss, you can see better, saves operative time, better cement technique, blah blah blah.” I agree.
But using a tourniquet too long can result in issues such as thigh pain, palsies, complications, ischemia and soft tissue damage.
So the message to my opponent is: “You’re just wrong, Viktor.”
I think Viktor read the wrong literature. The data supports me!
It’s not just about a tourniquet, it’s how you do the surgery—you must be meticulous.
I start with a spinal and use an iPack block in the knee along with IV antibiotics or tranexamic acid (TXA).
When you initially place the tourniquet, you must ensure that you don’t create a venous tourniquet as it would slow things down. I draw my incision in extension and make the incision in flexion. That’s the key—you must learn how to operate in flexion. The entire procedure needs to be done in flexion!
If I do anything in extension it takes milliseconds. Not seconds. Milliseconds.
I expose in flexion. I take the lateral meniscus out in flexion. I cauterize the lateral inferior geniculate in flexion. Then I make my cuts.
If the anesthesiologist is pumping in the blood pressure at 200, you have to turn the tourniquet up. If everyone’s working as a team, you can keep it down the whole time. Then you can do cemented or cementless—any fixation you want. But if you give a periarticular injection with epinephrine and use topical TXA, then drains are superfluous. You can do a plastic closure. You can have a field where it looks like you want it to, as opposed to the bloodbath situation that my wonderful colleague was describing.
If you wash that bone, you can do a cementless procedure. You can do anything you want. But here’s my point: doing it without a tourniquet is a technique. And in order to do it well you must do it on numerous occasions.
If you decide to go tourniquetless on a complex primary or revision or any difficult vascular path where skill is involved—you must have the ability to do it. And such skill acquisition doesn’t come overnight.
So, these are my take-home messages: The complications from using a tourniquet are well-known. But the merits of minimizing: My father, Chit Ranawat, always used to say, “Put a little rubber band on your finger. Put it on your finger and leave it there for 5 minutes, 10 minutes, 30 minutes on your finger. It hurts. It hurts bad. Right?”
If you are going to do a total knee in two hours, you had better learn how to do it tourniquetless. In every primary knee I teach my residents to learn this skill, which helps when performing complex and revision cases. Avoiding the use of a tourniquet allows the antibiotics and the TXA to go in intravenously and remain in the body for a longer period of time. I recommend the use of periarticular injections with epinephrine. And drains are unnecessary because when the procedure is finished, there is no massive blood loss.
You want to finish strong, so closure is important. Close it tight, clean, and dry. Use Dermabond or any glue.
The tourniquet is a thing of the past. Don’t be old. Be new. Be young.
You can do this Viktor!
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I have had many lymph nodes removed (cancer surgery) and am afraid of lymphedema in one or both legs if a tourniquet is used. Would it be better for me to find a surgeon who repairs the knee without using a tourniquet?