“OK, so you have a bloodless field using a tourniquet in TKA, ” says Dickey Jones. “But there are many downsides, such as nerve damage and a delay in the recovery of muscle function.” Steven MacDonald counters, “There is no clinical evidence of nerve damage or delays in muscle function recovery. And several studies show decreased overall blood loss.”
Jones, MacDonald Debate Tourniquetless TKA
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Great Debates
This week’s Orthopaedic Crossfire® debate is “Tourniquetless TKA: Let It Bleed.” For the proposition is Richard Jones, M.D. of University of Texas, Southwestern. Against the proposition is Steven MacDonald, M.D., F.R.C.S.(C) of University of Western Ontario. Moderating is Leo Whiteside, M.D. of the Missouri Bone and Joint Center.
Dr. Jones: “What’s the benefit of doing a total knee arthroplasty (TKA) with a tourniquet? You have a bloodless field…and there MAY be a better bone cement implant interface for fixation. The downside is nerve damage: direct (secondary to pressure); indirect (secondary to hypoxia). And there is a delay in recovery of muscle function.”
“There are vascular issues, such as altered hemodynamics with limb exsanguination. There is a 20% increase in circulatory volume when putting the Esmarch on for the tourniquet. And there is reactive hyperaemia when you release the tourniquet as well as a 10% increase in limb size that increases soft tissue tension and secondary pain.”
“There is a higher risk of vascular injury, particularly in artherosclerotic or calcified arteries. There is increased risk of DVT [deep vein thrombosis] with trauma to the vessel walls; also, increased levels of thrombin/antithrombin complexes, which leads to 5.3x more risk for large venus emboli propagation when you do transesophogeal echocardiograms.”
“We’ve also observed increases in wound healing disturbances and a higher propensity for wound leakage. In our early experience, we had high risk patients who had previous DVT or pulmonary embolus, multiple scarring and compromised cardiovascular structure. But for the last 15 years we have used no tourniquet on any primary or revision total knee.”
“A survey by the American Association of Hip and Knee Surgeons (AAHKS) found that 37% always use a tourniquet, 58% always use a tourniquet except if there is a vascular concern; only 5% of the entire AAHKS population use a tourniquet and then put it up during cementation.”
“Our operative protocol: regional anesthesia because it helps control blood pressure and reduce bleeding. The incision and approach is made with the knee in 90 degrees of flexion. When you’re there, you can do meticulous hemostasis…all vessels are readily seen and coagulated. We inject 0.25% ropivacaine with epinephrine periarticularly; posterior tissues are coagulated, and we do saline jet lavage. Then we deliver filtered carbon dioxide under pressure that dries and prepares the cement beds. We finish it up with three grams of tranexamic acid and 100ccs of saline topically administered after the cement sets. We do routine closure and a bulky, compressive Robert Jones-type knee dressing.”
“We found no real differences in blood loss. We thought that they had less postop pain, but we didn’t do Visual Analog Scales on these patients. They probably had a faster straight leg raise and perhaps better knee flexion, but I have no statistical evidence. There were definitely fewer wound healing disturbances. The cement penetration was equivalent.”
Dr. MacDonald: “I have performed total knees without tourniquets on a select few patients, i.e., the vasculopaths with no distal pulses and those in the cadaver lab. There are few randomized clinical trials to guide us, and there is no registry data, and there are many opinion pieces. So why use a tourniquet?”
“There is no argument that a tourniquet reduces intraoperative blood loss. In a meta-analysis of 15 papers with 1, 000 total knees there was significantly greater intraoperative blood loss without a tourniquet. That is intuitive. In this analysis, overall blood loss—intraoperative and postop—was not significantly different whether or not you use a tourniquet.”
“Several studies show decreased blood loss overall. In a randomized clinical trial (RCT) with 72 patients the tourniquet group had lower overall blood loss, but had slightly more postoperative pain.”
“In another RCT looking at using a tourniquet just for cementing or using it for the entire procedure, they were going to do over 200 cases, but they stopped at 65 because of the higher risk of transfusion if you’re only using it for part of the procedure. As Dickey noted, it’s a given that we want a dry bone surface for cementing; if you don’t have that the theoretical risk is late loosening. I use pulsatile lavage with a tourniquet, but there are different ways to get a dry bone surface. But they all come with a cost in terms of dollars and time. In a series of 3, 000 total knees they found a direct correlation between OR time and infection. They concluded that steps to minimize intraoperative delay should be instigated, and that care should be exercised when introducing measures which prolong the duration of joint replacement.”
“An excellent paper was published recently that demonstrated—tourniquet versus no tourniquet—about a five to six minute difference in operative time. So be cautious in changing your technique.”
“The stated downsides to a tourniquet are either basic science theories, rare, or short term. Vessel wall damage with increased DVT. A recent paper refutes it. All patients underwent an ultrasound and there was no difference between the groups. There is no clinical evidence for an increase in wound healing disturbances or delay in muscle function; nerve damage is rare.”
“Don’t use a tourniquet if you’re concerned about the theoretical risks. Don’t use one if you have alternate ways to achieve it that are cost neutral and don’t increase OR time. If you’re highly evolved, good looking and intelligent—like Dickey—you should use it.”
Moderator Whiteside: “We have a question from the audience.”
Audience member: “Don’t use a tourniquet on a diabetic. I don’t use a tourniquet until I cement. Protect the diabetics.”
Dr. Jones: “Good point.”
Moderator Whiteside: “Dr. Jones, is there any amount of tourniquet trauma that is acceptable? If you have a patient who you know who is going to bleed like hell, do you never use a tourniquet?”
Dr. Jones: “No sir.”
Moderator Whiteside: “Steve, is there ever a case in which you decide the patient may be too sensitive to tourniquet pain?”
Dr. MacDonald: “I use one for everyone unless someone is a vasculopath. The ones I find most frustrating are the morbidly obese patients where you put the tourniquet on and inflate it and they still leak out around that.”
Dr. Jones: “Even getting a tourniquet around there may take an extra large and then to apply enough pressure to make a difference to give you a bloodless field leads to more problems.”
Dr. MacDonald: “We have different thigh diameters like you do. I’ll go up to 350 on those patients; if they’re still bleeding out around that then it becomes a venous tourniquet so I release it and do the work around it. I will try to put it up for cementing in those cases.”
Moderator Whiteside: “So you’re ready to take this down and abort the tourniquet altogether.”
Dr. Jones: “Steve, is 350 your upper limit?”
Dr. MacDonald: “Yes.”
Moderator Whiteside: “Dickey, all the gear you use to achieve hemostasis…how expensive is it?”
Dr. Jones: “The Carbojet system is about $100 per case. What you’re buying is the sterile tubing to deliver it. The hardware and the gun are part of the OR system.”
Moderator Whiteside: “So the hospital does absorb considerable expense, including the disposable tourniquets. Steve, how do you manage tourniquets in a long, difficult case?”
Dr. MacDonald: “This usually pertains to revisions more so than a primary. I put the tourniquet up at the beginning and I keep an eye on the time. My bottom line is I want the tourniquet up for cementing. For most revision knees, we’ll get it up, cement, and then have to release the tourniquet for closure because we’re close to the two hour mark. I will often leave it up 10-15 minutes after the two hour mark, but that is my cutoff.”
Moderator Whiteside: “Is that at one time or the total for your entire case?”
Dr. MacDonald: “That’s one time. If you had a really long revision you could put it back up. It should be down for probably 30 minutes.”
Moderator Whiteside: “Thank you, gentlemen.”
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Discussion
This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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