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Orthopaedists question the need for tourniquets during TKA procedures
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A tourniquet applied during total knee arthroplasty may decrease blood loss and help reduce knee pain postoperatively, but it can also lead to potential nerve damage and vascular complications, according to two orthopaedic surgeons.
Richard E. Jones, MD, of Dallas, and Arun Mullaji, FRCS(Ed), MS, of Mumbai, India, addressed the merits of using a tourniquet during total knee arthroplasty (TKA) during a debate session.
While a tourniquet can offer reduced blood loss and offer better bone cement interface, Jones noted it can also lead to numerous complications for patients during a TKA, such as an increased risk of a deep venous thrombosis and more than a five times greater risk of propagation of large venous emboli and transesophageal echogenic particles.
Tourniquets may increase risks
“There are potential problems. There can be nerve damage, either direct or indirect, delay in recovery of muscle function as I think we saw from the last Academy[American Academy of Orthopaedic Surgeons meeting]. Remember, there can also be vascular issues. You are altering the hemodynamics of the limb and you have 15% to 20% of circulatory volume,” Jones said at the Current Concepts in Joint Replacement Winter Meeting.
One of the game changing elements in the field of TKA is the use of tranexamic acid (TXA) during a procedure to reduce blood loss, he said.
Better ways for success
Mullaji discussed his own prospective randomized double-blind study of 45 patients undergoing bilateral TKA. On one knee, a tourniquet was applied during cementing and on the second knee a tourniquet was applied from incision to cement hardening. Based on the outcomes, there was no statistically significant difference in functional improvement with either tourniquet technique, but more blood loss occurred in knees when a tourniquet was used only during the cementing phase.
Range of motion, knee pain and other factors were similar between the two groups, Mullaji said.
Furthermore, a tourniquet may provide a clear operative field and can potentially reduce blood-borne disease transmission through needle stick injuries, he noted.
He also cited studies which demonstrated residual blood at the bone-cement interface reduces adhesive/tensile strength of bone cement by almost 50%.
Perceived benefits
Jones said one perceived benefit of using a tourniquet during a TKA is the potential for a better bone-cement interface, balance and penetration, however, he uses another approach that does not involve a tourniquet to improve the cement interface and penetration.
“We deliver filtered carbon dioxide through a CarboJet CO2 Lavage System (Kinamed; Camarillo, Calif., USA). It dries and prepares the bone beds for cementation much like a dentist does when he is cementing a crown. We then use local TXA — 3 grams per 100 cc — and routine closure and compressive dressing,” Jones said.
However, in a study Mullaji discussed, the use of a tourniquet helped achieve a thicker cement mantle during TKA.
“This study shows the effect of tourniquet on the cement mantle thickness being much thicker when you use the tourniquet against not using it. I would suggest you should use a tourniquet because it helps to reduce blood loss, it provides a much better cement mantle, improves the clarity and it does not lead to any additional complications,” he said.
Tranexamic acid may replace tourniquets
Jones’ main argument was too many variables exist when using a tourniquet, so he questioned why one should be used at all, especially with TXA now being available for the procedures.
“TXA is a huge game changer in what we do, so there will not be any differences in blood loss. Who really has to do a transfusion anymore during one of these procedure?” he said.
Mullaji mentioned that studies in the literature support the use of a tourniquet from incision to cementing to improve the cement mantle, reduce blood loss and the risk of a blood transfusion, improve clarity and [will] not result in additional complications. – by Robert Linnehan
- References:
- Jones RE. Paper #71.
- Mullaji A. Paper #72. Both presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 10-13, 2014; Orlando, Fla., USA.
- For more information:
- Richard E. Jones, MD, can be reached at University of Texas Southwestern Medical Center, Department of Orthopaedic Surgery, 12606 Greenville Ave., Dallas, TX 75243, USA; email: dickeyjones@gmail.com.
- Arun Mullaji, FRCS(Ed), MS, can be reached at Breach Candy Hospital, Mumbai 400035 and The Arthritis Clinic, 101 Cornelian, Kemp’s Corner, Cumballa Hill, Mumbai, 400036, India; email: arunmullaji@gmail.com.
Disclosures: Jones reports he receives royalties for intellectual property from DePuy Synthes Joint Reconstruction, DeRoyal and Innomed and he has stock ownership in Amedica, Johnson & Johnson, Kinamed and Omni. Mullaji reports he receives consulting fees for design and teaching from Biomet and receives royalties and consulting fees for design, consulting and teaching from DePuy Synthes Joint Reconstruction.