At the 2019 Orthopaedic Summit: Evolving Technologies (OSET) held in Las Vegas this past December, two internationally-acclaimed orthopedic surgeons—Viktor Krebs, M.D., of Cleveland Clinic and Amar S. Ranawat, M.D., of Weill Cornell Medical College and Hospital for Special Surgery—squared off in a debate about how they would treat a 56-year-old marathon runner for his first total knee who requested a tourniquetless procedure, yay or nay?
First up was Viktor Krebs, M.D., who argued for the use of tourniquets. His point of view was “Pro: You Need the Tourniquet to See the Anatomy & Cement Properly.”
Dr. Krebs: In total knee replacement a tourniquet is required in order to appropriately visualize the anatomy and cement. If you are doing a tourniquetless knee, it is essentially bloodletting, which is not supported by the current literature.
The tourniquet has been used during total knee replacement since the first such procedures in 1968. Not using one means that you’re putting it up and letting your patient bleed. However, when you look at the data, patients actually don’t end up getting transfusions like you would expect and want.
Currently, tourniquets are used by up to 90% of surgeons doing total knee replacement and it’s been a clinical standard for generations. This is supported by the literature.
The tourniquet during total knee is used with the intention of minimizing intra-operative bleeding—not blood loss—improving visualization and optimizing dry bone surfaces to allow better cementing techniques.
A tourniquet makes it possible to visualize the knee in its entirety. In particular, it allows surgeons to see into the back of the knee, thus helping to ensure a solid clinical outcome.
Not using a tourniquet results in a substantial amount of blood in the field—not a situation where I would use cement. Although press fit knees work very well where blood exists, that is not an ideal bed for cementation.
Also note that a tourniquet is used with the intention of protecting your OR team from blood splatter. If you’re not using a tourniquet or if you’re using one that doesn’t work, there is blood being dispersed throughout the operating room. And if your patient has HIV or hepatitis this is an especially important consideration.
The literature reveals mixed results for actual intra-operative blood loss, the incidence of DVT [deep vein thrombosis], surgical site infection, and pain related to tourniquet use. According to the literature, tourniquet use isn’t very controversial.
I conducted a literature search from 2010 forward and found over 50 prospective studies, including roughly 25 to 26 randomized control trials, and over 15 meta-analyses of those prospective studies. I am not sure if my colleague from HSS has read these.
A randomized double-blind study of 200 patients from Rothman Orthopaedic Institute—100/100 randomized—found that tourniquet use significantly decreased blood loss and did not adversely affect postoperative functional outcomes.
Tourniquet use is safe and effective. And concerns about the deleterious effects on function and pain may not be justified.
In a JBJS article of research conducted in a Swedish rehabilitation facility, investigators reported no improved knee motion without a tourniquet. In the non-tourniquet group, they found more pain for a short period of time and no clinical relevance to improved mobility. In addition, all large meta-analyses have found no difference between postoperative pain and range of motion.
In my opinion, the duration of tourniquet use, and cuff pressure are the most important considerations. The pressures relate to the tourniquet width and thigh girth of the patient. It’s not the tourniquet—it’s the tourniquet time.
It is widely known that infection and DVT are linearly related to the length of time in surgery. Thus, the longer the tourniquet use, the larger the chance of complications.
The data will support use and non-use, but I choose to use them. Why? Because they work. It is a bloodless field and you can see what you’re doing. In conclusion, tourniquet use is safe and effective during total knee replacement and you should use it.
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?