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Surgery without tourniquet may prove advantageous vs tourniquet use
Patient selection is key when using a tourniquet, but specific practices may improve tourniquetless surgery
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Although tourniquet use during surgery has its advantages, presenters at a meeting noted in some cases it may do more harm than good.
“Why do we use a tourniquet? We use it because it works. It gives you a nice, clean surgical field, less blood loss and reproducible cement technique, and this has been my practice for 20 years,” Jose A. Rodriguez, MD, hip and knee surgeon at Hospital for Special Surgery, said at the Current Concepts in Joint Replacement Winter. “But let’s be clear: There are downsides, whether it is tissue ischemia, direct pressure damage or the embolic load that occurs with tourniquet release.”
Tourniquet vs no tourniquet
Although Rodriguez found a maximum drop in hemoglobin and a slightly higher hematocrit in his patients with limited tourniquet use, on closer examination he found non-statistically significant increases in pulmonary embolism, as well as stiffness that required manipulation.
Nerve damage has also been associated with tourniquet use for long periods of time, Rodriguez noted.
“All those complications … are related to the tourniquet times and we know … that infection and [deep vein thrombosis] DVT are linearly related to the length of the surgery,” Robert E. Booth Jr., MD, said. “If you are doing an hour-and-a-half total knee, you are going to have three times the infection and DVT rate as a half-hour procedure.”
Published studies in which tourniquet use was compared to no tourniquet use showed a marked reduction in pain and opioid use, better KOOS scores and range of motion, and improved VAS for pain and timed up and go test scores for the no tourniquet group, according to Rodriguez.
In cemented total knee arthroplasty cases, Rodriguez said the literature has shown patients who received no tourniquet, or a tourniquet used during cementing only, had no differences in cement penetration compared with when a tourniquet was used during the entire TKA procedure. However, patients experienced improved pain and Knee Society Scores with no tourniquet or with a tourniquet used during cementing only.
Advice for tourniquet use
Booth noted patient selection is important when using a tourniquet. Patients with calcifications, Monckeberg sclerosis and patients with stents or bypasses are not good candidates for tourniquet use, he said.
“There is no predictive test. The ankle brachial index is not helpful. Obesity often obviates the use of a tourniquet altogether and the worst thing of all is a slow surgery,” Booth said.
Although surgeons know tourniquets come in different lengths, Booth said few of them “realize they come in different widths, and so the pressure of a tourniquet is related more to its width than its length.”
Rodriguez suggested surgeons should have anesthesiologists provide a systolic blood pressure of less than 90 mm Hg and most of the surgery should be performed with the knee in flexion when a tourniquet is not used. When using cement, irrigation should be performed both before and after the cement is mixed, according to Rodriguez.
“We use the suction at 90° and it takes out a lot of the blood and fatty contents quite effectively allowing an appropriate and reproducible cement interdigitation to be achieved,” Rodriguez said. “I would suggest that using this technique, you can get reproducible cement mantles just about every single time with no difference —tourniquet vs. [no] tourniquet.” – by Casey Tingle
References:
Booth, RE Jr. Paper 64. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2018; Orlando.
Rodriguez JA. Paper 63. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2018; Orlando.
For more information:
Robert E. Booth, Jr., MD, can be reached at Jefferson Health, 3B Orthopaedics, 601 Walnut St., Suite L50, Philadelphia, PA 19106.
Jose A. Rodriguez, MD, can be reached at 541 E. 71st St., New York, NY 10021; email: ironsm@hss.edu.
Disclosures: Rodriguez reports he receives consulting fees and royalties for consulting and design from Conformis, Exactech, Medacta International SA and Smith & Nephew. Booth reports no relevant financial disclosures.