This week’s Orthopaedic Crossfire® debate was part of the 32nd Annual Current Concepts in Joint Replacement® (CCJR), Winter meeting, which took place in Orlando this past December. This week’s topic is “The Tourniquetless TKA: Let It Bleed.” For the proposition is Richard E. Jones, M.D., University of Texas, Southwestern, Dallas, Texas. Opposing is Keith R. Berend, M.D., Mt. Carmel New Albany Surgical Hospital, New Albany, Ohio. Moderating is Kelly G. Vince, M.D., F.R.C.S.(C), Whangarei Hospital, Whangarei, New Zealand.
Dr. Jones: Let it bleed. What are the benefits of using a tourniquet? Well, you operate in a bloodless field and potentially you have a better bone cement implant interface for fixation. I say potentially because that’s now been proven not to be true.
Potential problems with tourniquet. Just think about it, augggghhh. Delay in recovery of muscle function. Slower functional recovery. Altered hemodynamics when you exsanguinate the limb because you get a 15-20% increase in circulatory volume. A reactive hyperemia when you release the tourniquet and a 10% increase in size of the limb. Vascular injury is certainly high risk in those patients with calcified atherosclerotic vessels.
More vascular risk of DVT [deep vein thrombosis] with direct trauma to vessel walls; increased levels of thrombin/anti-thrombin complexes and a 5.3 times the risk increase with large venous emboli propagation looked at with transesophageal echocardiography. Potential problems with increase in wound healing disturbances, higher propensity for wound leakage, and, shown to show, slower functional recovery.
For the last 15 years, we’ve gone with no tourniquet on any TKA, primary or revision. Our operative protocol is regional anesthesia to control blood pressure and reduce bleeding; we make our incision with the knee flexed to 90 degrees; it’s amazing how little bleeding occurs; and you can meticulously obtain hemostasis because you see all the vessels. They’re readily coagulated and we use an argon beam coagulator.
Our operative protocol is 0.25% ropavicaine with epinephrine injected periarticular, coagulate all those posterior vessels when you’re doing your flexion tension balancing and can look at it, then saline jet lavage with antibiotics.
We use filtered carbon dioxide delivered under pressure with a CarboJet to dry and prepare the bone beds, very much like the dentist will blow your tooth out before he cements a crown. We use tranexamic acid, either local or systemic, or both. We use compressive dressing.
In our center we observed no differences in blood loss or transfusion rates. Our patients have less post-operative pain, faster straight leg raising and knee flexion gains, fewer wound healing disturbances and consistent cement penetration and mantles in the post-operative films.
So in the end, our recommendation is very similar to the Rolling Stones: Let It Bleed.
Dr. Berend: So I’ve been asked to talk about the tourniquet and the fact that throughout my entire training and throughout my entire career, I’ve always used a tourniquet. This is the first time that I’ve actually gone and looked at the literature by Seth’s definition to try to oppose the fact that we should not use a tourniquet. And I think by the end of this of 5 minutes and 40 seconds, perhaps we will come to a neutral ground.
First of all, tourniquets have always been part of my routine. So we position the patient, we administer antibiotics, we put on the tourniquet, we set the pressure, we get ready for the time, we prep, we drape, we do the time-out, we inflate the tourniquet and we do the operation. We deflate the tourniquet and we walk out of the room and we say “Hi” to the family.
The tourniquet was used as far back as the Roman Empire with bronze and leather devices to basically control bleeding in times of amputation. And the bottom line was, we need to save the life without regard for the limb. Well, if we extrapolate that forward another, 2, 000 years, are we saving lives by using tourniquets today? I’m not really sure.
The term tourniquet was coined by Jean Lous Petit—it actually means to turn—and it was the leather strap and the stick in the leather strap and you would turn the strap to exsanguinate the limb. Again, for the use of amputations. Lister started using it the 1800s to use a bloodless field. Cushing described a pneumatic tourniquet in the early 1900s. And today it’s thought that almost 15, 000 times a day the tourniquet is used for lower extremity surgery.
I do think it enhances visibility. There’s less blood during cementation. It has been described in multiple studies, that there is less intraoperative blood loss.
However, the total blood loss and the transfusion requirement have not been shown to have an advantage of using a tourniquet or not using a tourniquet. I will say, personally, on trips like Operation Walk when we go to places like Guatemala and Nicaragua, where we use IV heparin for the operation for DVT prophylaxis, the tourniquet use is absolutely required because once you give someone some IV heparin, there is significant bleeding without the use of a tourniquet.
It was described in a most recent article, now 20 years after an article by Ritter (JBJS-A, 1994), that there is no difference in an RSA study of a small number of knees. However, that is with the meticulous preparation of the bone cement interface. If you don’t use a tourniquet and you don’t meticulously prepare that cement interface, the survivorship of knee replacement is significantly worse as shown by Ritter over 20 years ago.
I think if you use a tourniquet, it makes surface preparation a little bit easier. If you’re not going to use a tourniquet, methods like the CarboJet, irrigation, drying the interfaces may be required.
Obviously, if the tourniquet is used improperly, if the operation is not efficient, if the pressure is too high, direct neurologic results can occur and I do think that is a risk. The risk, however, is very, very low.
There are two studies…one from Mike Berend and one from our institution that would say that if you’re going to use a tourniquet, you need to deflate the tourniquet prior to defining whether or not you need to perform a lateral release. The lateral release rate went from 71% to 22% in one study, just by deflating the tourniquet. Constriction of the quad clearly affects the need for lateral release.
In terms of neurological risks, it’s been defined as less than 1 in 3, 000, so it’s very, very rare. The convenience of a tourniquet outweighs that very, very slight risk.
There is no free lunch. Tourniquet use has been clearly shown to decrease surgical time. It lowers intraoperative blood loss, but there’s higher total blood loss. In one study, DVT and surgical site infection/wound healing were “relatively augmented”. I’m not exactly sure what that means, but basically looking at the data they were both higher. So in a meta-analysis, use of a tourniquet increases risk of DVT and increases risk of surgical site infection or wound closure.
The bottom line after doing this research and trying to debate Dickey, for decades he has advocated “let it bleed.” And I will submit that he’s probably right. I think it’s a surgeon preference and I will continue to use a tourniquet.
Moderator Vince: Well, Keith, I’d have to say that’s far from a compelling argument.
Dr. Berend: Literally, this is the first time I’ve researched this subject and as I did I could not find anything that would refute what Dickey’s been telling us for 20 years.
Moderator Vince: Dickey, how much time do you spend obtaining hemostasis?
Dr. Jones: It’s just part of opening of the procedure and you can get it all right there.
Dr. Berend: Two minutes. The data suggests that not using a tourniquet may be beneficial. The operative time is slightly longer, but it’s not like 20-30 minutes longer. It’s just statistically longer.
Moderator Vince: Can you come up with one justifiable reason why you still use it?
Dr. Berend: For me, it’s convenience. It’s saving that little bit of operative time, not having to use CarboJet and things that may increase cost of the operation and increase time. The convenience of using the tourniquet is why we use it.
Moderator Vince: What about tranexamic acid—has that changed the game?
Dr. Berend: I think TXA has changed the game tremendously, in terms of transfusion requirements; overall loss of hemoglobin, but also the subtle things like the wound looking better; less swelling; less bleeding after surgery. That isn’t perhaps a transfusion trigger bleeding, but wound looks better, knee looks better, range of motion is better.
Moderator Vince: So the argument that using the tourniquet might result in higher overall blood loss, could be helped with tranexamic acid.
Dr. Jones: Well, the timing of the tourniquet release is important. There is more bleeding and more blood loss if you release the tourniquet before you close. And that’s because of the reactive hyperemia that we talked about with tourniquet release. At least if you release the tourniquet after you close and after you put a compressive dressing on, then you’re going to have less blood loss and you’re going to be able to tamponade a lot of that blood loss.
Question from the audience: I really never noticed the tourniquet pain post-operatively until I started using multi-modal pain control with Exparel, but I sure notice it now. That’s why I’m very interested in this talk. Have you noted more pain post-operatively from the tourniquet?
Dr. Berend: That’s a great question and I think in terms of game changers, our multi-modal pain management protocol has made the early post-operative period where the knee itself doesn’t hurt. The block, adductor canal, sciatic blocks, local infiltration with ropavicaine, etc., the knee doesn’t hurt a lot. Those patients then will notice some leg pain and I think it’s from the tourniquet or from the hyperemia. It’s a great point.
Dr. Jones: There are two things that have really been blessings to orthopedic surgeons: multi-modal pain control, and to our patients as well, TXA.
Moderator Vince: Is there a situation where you would use a tourniquet?
Dr. Jones: We always put it on just in case because I deal with residents and we have circumstances that are somewhat different. It’s on and ready to go if you need it. But you don’t want it to be a venous constrictor when you put it on.
Moderator Vince: And Dickey you have to buy Keith a cup of coffee, please.
Dr. Jones: Thank you Kelly and thank you audience very much. God bless us all.
Please visit www.CCJR.com to register for the 2016 CCJR Winter Meeting, – December 14 – 17 in Orlando.
