Tourniquet use may increase risk for serious adverse events after knee replacement
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Published results showed use of a tourniquet in knee replacement surgery may increase the risk for serious adverse events and may be associated with higher postoperative pain.
Peter D.H. Wall, PhD, FRCS(Orth), and colleagues analyzed pain, function, global assessment of success, health-related quality of life, serious adverse events, cognitive function and survival of the implant among 41 randomized controlled trials that compared knee replacement with and without the use of a tourniquet.
Results showed patients may have higher postoperative pain scores at day 1 when a tourniquet is used, with an absolute difference of 12.5% higher pain scores and a relative difference of 19% higher pain scores with the use of a tourniquet. Researchers also found tourniquet use may lead to higher risk for serious adverse events.
However, researchers noted tourniquet use makes little or no difference in function at 12 months. This is based on a minimal clinically important difference (MCID) of 5.3 for Knee Society Score and 5 for Oxford Knee Score, according to results. Results also showed tourniquet use may have little or no effect on success or quality of life at 6 months postoperatively. Based on the studies reviewed, researchers noted it was uncertain if tourniquet use influenced implant survival, while data on cognitive function could not be extracted for analysis due to being incompletely reported.
“The evidence indicates that knee replacement surgery performed with a tourniquet increases the risk of serious complications needing additional healthcare, many of which might be avoided if a tourniquet is not used,” Wall told Healio Orthopedics. “The evidence may be a compelling reason for many surgeons to change practice and not use a tourniquet during knee replacement surgery.”
Perspective
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This Cochran Library systematic review is designed to consider all published, randomized controlled studies and large cohort studies that address the specific question of tourniquet use in TKA. The value of this review lies in both the rigor of the analysis and the concerted effort to consider the bias of each study based on its scientific design. The authors breakdown the specific outcome measures, such as early pain, function, adverse events, etc., which is most useful. Based on these mostly short-term outcome measures, the authors conclude that surgery with a tourniquet does not confer meaningful clinical benefit.
The deficiency in this analysis lies in the fact that tourniquet use is meant to clear the surgical field for expeditious surgery and, more importantly, optimal cement penetration into the cancellous bone for long-term fixation and durability of the arthroplasty. As such, the primary outcome of the use of the tourniquet is not being assessed in this short-term analysis.
With increasing use of non-cemented implants, where clean bony surfaces offer no benefit, the value and applicability of these finding will become more evident.
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