At Issue: Tourniquet removal

Orthopedics Today asked doctors the following question: During extremity surgery, do you deflate the tourniquet before wound closure? Why do you prefer the method you use?

Issue: September 2006

F. Alan Barber, MD [photo]
F. Alan Barber

F. Alan Barber, MD

The vast majority of my lower extremity procedures are knee arthroscopies. A tourniquet is not needed for a simple knee arthroscopy and not a good idea for any procedure that can be performed without one (1,2). ACL reconstruction is the principal reason I use a tourniquet.

The tourniquet is deflated before wound closure and as soon as possible to reduce neurologic damage to the limb and to identify any bleeders so that hemostasis can be achieved.

Dobner JJ, Nitz AJ. Postmeniscectomy tourniquet palsy and functional sequelae. Am J Sports Med. 1982; 10:211-214.

Nitz AJ, Dobner JJ. Upper extremity tourniquet effects in carpal tunnel release. J Hand Surg [Am]. 1989; 14:499-504.

F. Alan Barber MD, FACS, Plano Orthopedic and Sports Medicine Center, 5228 W. Plano Parkway, Plano, TX 75093; (972) 250-5700; knees2do@aol.com.

Amy L. Ladd, MD [photo]
Amy L. Ladd

Amy L. Ladd, MD

I deflate the tourniquet depending on the procedure and its length. In general, I remove the tourniquet after wound closure and upon dressing application. The exceptions include when skin viability or when wound dehiscence may be a problem, such as pediatric congenital cases which require skin graft, and cubital tunnel surgery with an epicondylectomy.

Amy L. Ladd MD, Professor, Department of Orthopaedic Surgery, Chief, Pediatric Hand Clinic, Lucile Packard Children’s Hospital, Robert A. Chase Hand & Upper Limb Center, SUMMIT Outreach Director (summit.standford.edu); (650) 723-6796.

Richard S. Laskin, MD

I normally deflate the tourniquet prior to closure. Although there are numerous studies showing that “in general” the amount of blood loss is the same whether you do this or leave it inflated until the end of the procedure, my concern is not about means but rather about outliers. There is the occasional patient in whom there is an arterial bleeder that requires specific coagulation lest a large hemarthrosis occur.

If the tourniquet was left inflated until the end of the case I would not be aware of this potential problem source. Likewise, there have been many studies, mainly in the sports medicine literature, showing that the longer the tourniquet is inflated, the more “damage” there is to the quadriceps musculature. Having said all of that I feel at present that a better regimen would be to place a tourniquet about the upper leg but not inflate it except just prior to cementing so as to allow cleaning of the bony surfaces.

Richard S. Laskin, MD, Chief of the Arthroplasty Division, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021; (212) 606-1041; laskinr@hss.edu.

William Robb, III, MD

For total knee replacement, I now always release the tourniquet prior to closure. There are two advantages: It reduces the tourniquet time and it allows a more consistent hemostatic wound closure.

For many years I closed wounds while the tourniquet remained inflated but occasionally significant bleeding points were not recognized and caused either a hemarthrosis or hematoma. Symptomatic or clinically significant knee swelling is rare with “real” surgical hemostasis prior to closure. Additionally, tourniquet release prior to wound closure has not been associated with added blood loss or need for transfusion.

William Robb, III, MD, Chairman, Department of Orthopaedic Surgery, Evanston Northwestern Healthcare 2401 Ravine Way, Glenview, IL 60025; (847) 998-5680; w-robb3@northwestern.edu.

Barry P. Simmons, MD [photo]
Barry P. Simmons

Barry P. Simmons, MD

I virtually always release the tourniquet before wound closure. Many years ago I was not as inclined to release the tourniquet before the dressing was applied, however, I found a sufficiently high incidence of scarring because of bleeding, swelling and pain that I switched to releasing the tourniquet.

Working on smaller structures the wound problems from post-tourniquet bleeding seems to be magnified. Thus, I always get good hemostasis before wound closure.

Barry P. Simmons, MD, Director, Hand and Upper Extremity Division, Department of Orthopaedics, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115; (617) 732-8550; bsimmons@partners.org.