Tourniquet use may impact antibiotic tissue concentration during TKA
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Key takeaways:
- Antibiotic tissue concentrations may be lower among patients who undergo TKA with a tourniquet vs. without it.
- Tourniquet use may inhibit the ability of antibiotics to cover pathogens responsible for infection.
Use of a tourniquet may reduce local tissue concentrations of cefazolin, which could increase the risk of periprosthetic joint infection for patients undergoing total knee arthroplasty, according to published data.
Julien Montreuil, MD, MSc, orthopedic surgeon from the division of orthopedic surgery at McGill University in Montreal, and colleagues performed a prospective, randomized clinical trial of 59 patients who underwent primary TKA between March 2022 and June 2023.
Montreuil and colleagues randomly assigned 29 patients to undergo surgery with a tourniquet and 30 patients to undergo surgery without a tourniquet. According to the study, they used liquid chromatography-tandem mass spectrometry to assess the local tissue concentration of cefazolin in fat, synovium and bone at 60 minutes after infusion.
Compared with no tourniquet, the use of a tourniquet was associated with significantly lower mean local tissue concentrations at 60 minutes after infusion in fat (16.9 μg/g vs. 10.8 μg/g), synovium (25.8 μg/g vs. 18.9 μg/g) and bone (19.4 μg/g vs. 11.8 μg/g).
Montreuil and colleagues noted the mean local tissue concentration for patients in the tourniquet group was insufficient to cover pathogens with high minimum inhibitory concentrations such as coagulase-negative staphylococci and other pathogens responsible for PJI.
“The study underscores the adverse effect of tourniquet inflation on tissue concentration of antibiotics and raises questions regarding cefazolin’s effectiveness against pathogens with higher minimum inhibitory concentrations,” Montreuil and colleagues wrote in the study.
Perspective
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This randomized trial compared total knee replacement with and without tourniquet use, sampling systemic and local cefazolin concentrations in fat, synovium and bone every 30 minutes following infusion. The tourniquet group consisted of 29 patients, and 30 patients were in the non-tourniquet group.
By 60 minutes, serum of cefazolin levels were the same in both groups, while all three tissues sampled demonstrated statistically lower tissue concentrations in the tourniquet group compared with the non-tourniquet group. Individuals having a BMI greater than 30 mg/kg2 had reduced local tissue concentrations in the fat tissue compared with those without obesity at 30 and 60 minutes.
While infection data as an endpoint are limited, a recent meta-analysis of 14 randomized control trials found that the pooled incidence of infection in the tourniquet group was significantly higher, with an odds ratio of 1.9.
Tourniquet use in lower extremity surgery is well established with decades of positive outcomes. However, increasingly granular data demonstrating the potential benefits of limiting the use of this tool are growing.
Reference:
Magan AA, et al. J Exp Orthop. 2022;doi:10.1186/s40634-022-00485-9.
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