This week’s Orthopaedic Crossfire® debate was part of the 33rd Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Tourniquetless TKA: Let It Bleed.” For is Robert L. Barrack, M.D., Washington University School of Medicine, St. Louis, Missouri. Opposing is Adolph V. Lombardi, Jr., M.D., Mt. Carmel New Albany Surgical Hospital, New Albany, Ohio. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts.
Dr. Barrack: The first 25 years of my career I used a tourniquet for total knee routinely. The last several years I have not used a tourniquet. I have more confidence when I’m debating a topic on which I have extensive personal experience on both sides.
My personal observation has been that my patients are doing better clinically. It has not increased the difficulty, OR time or blood loss when I use a tourniquet in a very minimal amount when I cement. But most of my knees are cementless, so I don’t use a tourniquet at all. But that’s anecdotal and you didn’t come here to hear anecdotal data.
There’s an amazing amount of literature on this topic. The consensus is pretty strong. It’s convenient for surgeons to have a bloodless field and I do use a tourniquet for a few minutes most of the time just before I cement, but in some cases I don’t even do that.
I put it in a category of an orthopedic tradition.
Is it necessary? For lower extremity surgery where you are operating on ligaments and nerves and vessels, I could see where a bloodless field would be necessary, but for total knee, not really.
A number of traditions in knee replacement have gone by the wayside because they are not supported by evidence (CPM, drains, PCA pumps, femoral nerve blocks). Tourniquets may also be the case. An RSA study (Ejaz, et al., J Arthroplasty 2015) found that usually by the time you’re cementing the field is so dry you don’t even need to put up a tourniquet. In this study, they didn’t use a tourniquet and found no difference in implant migration.
So why not use a tourniquet? The highest-level studies show that range of motion is consistently better when a tourniquet was not used. Or if it was used, it was only used for a brief portion of cementing, which is 10 minutes, not an hour. Functional recovery and strength—Doug Dennis, one of our former Knee Society presidents, recently published a randomized trial that showed there’s more strength at 3 weeks and 3 months and he attributed this to the lack of muscle damage when you don’t use a tourniquet.
Perioperative pain. Very strong evidence in favor of not using a tourniquet in order to decrease pain postoperatively and increase recovery. Edema, swelling… studies show that the limb swells 10% from its original value, half because of return of blood, half because of reactive hyperemia.
Longer tourniquet times have been associated with increased wound drainage and decreased transcutaneous oxygen levels that slow wound healing.
We all know that when you release a tourniquet, you have a rush of embolic events and certainly embolic events are probably unavoidable, but it’s better to have them at a slow pace throughout a procedure rather than all at once for some of the older patients.
