Jones v. Mullaji: The Tourniquetless Total Knee

“Let it bleed, ” argues Dickey Jones. “Tranexamic acid has been a game changer, and use of a CarboJet increases cement penetration. You don’t need a tourniquet.” Arun Mullaji says, “You should use a tourniquet because it helps reduce blood loss, provides much better clarity, and it gives you a better cement mantle.”

This week’s Orthopaedic Crossfire® debate is “The Tourniquetless TKA: Let it Bleed.” For the proposition is Richard E. Jones, M.D. of the University of Texas, Southwestern. Arun Mullaji, F.R.C.S.(Ed), M.S. of The Arthritis Clinic in Mumbai, India is in opposition. Moderating is Robert Trousdale, M.D. of Mayo Clinic.

Dr. Jones: “The benefit of a tourniquet is a bloodless field, and possibly a better bone-cement-endplate interface for fixation. But there are problems. There may be direct or indirect nerve damage, a delay in the recovery of muscle function, and vascular issues are possible. You alter the hemodynamics of the limb with exsanguination and get a 15-20% increase in circulatory volume. There may be reactive hyperaemia with tourniquet release and get 10% increase in limb size, which increases soft tissue tension and causes secondary pain. There is a higher risk of vascular injury in patients with calcified atherosclerotic arteries.”

“There is increased risk of deep vein thrombosis (DVT) with direct trauma to the vessel walls, increased levels of thrombin/antithrombin, and a 5.3x more risk for large venous emboli propagation and transesophageal echogenic particles. We have observed an increase in wound healing disturbances, and a higher propensity for wound leakage. One of the game changers may be the local application of tranexamic acid.”

“For the last 12 years we haven’t used a tourniquet on any primary or revision total knee arthroplasty [TKA]. A survey done by the American Association of Hip and Knee Surgeons (AAHKS) found that 37% of surgeons always use a tourniquet and 58% always except with vascular concerns; 5% were only using it during cementation.”

“Our operative protocol is regional anesthesia, incision, and approach made in 90 degrees of knee flexion. You would be very surprised at how little it bleeds. There is meticulous hemostasis because you’re looking at them—we use an argon beam coagulator. We use ropivacaine with epinephrine injected periarticular, and we coagulate the posterior tissues—particularly during the flexion-tension balancing when you can access it. We also use copious saline jet lavage.”

“We deliver filtered carbon dioxide through a CarboJet, which dries and prepares the bone beds for cementation. We use local tranexamic acid, then routine closure and compressive dressing. Cement penetration is improved and the CarboJet resulted in a 35% increase in cement penetration versus the use of pulsatile lavage only. That is important because increased penetration improves the cement mantle toughness…and increased penetration reduces bone-cement interface stresses. And it counters bone resorption over time.”

“So our recommendation follows that of the Rolling Stones…let it bleed.”

Dr. Mullaji: “You should use a tourniquet because it helps reduce blood loss, provides much better clarity during surgery, and it actually gives you a better cement mantle. We know that blood at the interface reduces the adhesive and tensile strength by almost 50%. So it should be a simple matter of comparing series done with and without a tourniquet and looking at the outcomes of blood loss, pain, functional recovery, complications, and operative time. Unfortunately, it’s not that easy because there are a number of confounding variables in these studies (tourniquet pressure, time of application, the anesthesia used, etc.).”

“We did a prospective, randomized double blind study. The number of patients (45) was based on a power analysis. These were bilateral patients undergoing cemented navigated total knees who all received a spinal epidural; they were all performed by one surgeon. On one knee we used a tourniquet during cementing and on the other knee we used one from incision until the cement had hardened.”

“We excluded patients with a very thick circumference of the thigh, those with peripheral vascular disease and bleeding disorders, and people with significant differences in deformity on the two sides. We measured pulse, blood pressure, SpO2 (peripheral capillary oxygen saturation) before and after tourniquet release, blood loss, pain, thigh girth and function. Preoperatively there were no differences between the two limbs in all of these variables; postop, there were no differences in heart rate, mean arterial pressure, SpO2, knee pain, thigh pain, range of motion (ROM) or thigh girth. And there were no major complications. But postop differences in blood loss were significantly higher in the group where the tourniquet was used only for cementing (group one). Thigh pain in group two was slightly more than in group one during the first four days postop. And extensor lag was slightly less in group one (but only on day one).”

“In a meta-analysis of randomized trials (Alcelik et al., The Journal of Arthroplasty, 2012) where a tourniquet was not used, they found that the total and intraop blood loss was less with a tourniquet. But they found no difference in the duration of surgery, deep vein thrombosis, pulmonary embolism, etc.”

“In a randomized clinical trial (RCT) from Taiwan (Tai et al., The Journal of Bone and Joint Surgery [Am], 2012) they had a greater drop in hemoglobin, hematocrit, and a higher calculated blood loss without a tourniquet. This trial (Kvederas et al., Knee Surgery, Sports Traumatology, Arthroscopy, 2013) used tourniquets only for cementing and found that the blood loss was higher than if they had used a tourniquet for the entire surgery. A study by Larry Dorr found no important clinical differences between using a tourniquet throughout the surgery versus using one only during cementation.”

“So I would suggest using a tourniquet because it does help reduce blood loss, it provides a much better cement mantle, improves the clarity, and it does not lead to any additional complications.”

Moderator Trousdale: “Dickey, can you explain why—in the last five years—there has been a surge in surgeons not using a tourniquet?”

Dr. Jones: “Maybe because I’ve been talking about it at this meeting for 10 years, showing the penetration of what Seth does in education. As for blood loss, tranexamic acid has been a huge game changer…who ever has to do a transfusion anymore? ”

Moderator Trousdale: “The blood loss data is confounding. Arun, how do you measure blood loss intraoperatively?”

Dr. Mullaji: “It is pretty much gauged by sponges used to measure before and after. And we measure the amount of fluids given for irrigation. We added the two and subtracted the weight of the increase in sponges. Postop blood loss was what was in the drains.”

Moderator Trousdale: “Those measurements are kind of a joke. I lose 3cc’s during a pelvic osteotomy…that’s a bit of an underestimation, right? Do you admit that there is a lot of data to support that transfusion rates are similar with or without a tourniquet?”

Dr. Mullaji: “There is so much variability. The common conclusion in most of these meta-analyses is that these studies are all flawed. And there are six different methods of calculating blood loss. I agree that things have changed with tranexamic acid, but there aren’t any good studies using tranexamic acid to study blood loss with and without a tourniquet.”

Moderator Trousdale: “Dickey, does it matter how thick the tourniquet is or how you put it on?”

Dr. Jones: “There is a lot of variation. If you have a very large thigh and you’re trying to put a tourniquet on you will mostly get venous back bleeding and you don’t get any inhibition of actual blood flow. People go 100 over their systolic pressure, but if you have a small tourniquet you’re going to apply more pressure per unit area than with a large tourniquet.”

Moderator Trousdale: “Arun, gives us some techniques.”

Dr. Mullaji: “It’s important to use a sufficient amount of padding under the tourniquet, and to inflate the pressure to about 100 more than systolic. It’s important to have hypertensive anesthesia where possible because it helps to get the mean limb occlusion pressure much lower. Use it only until the cement hardens and then immediately deflate it. We wouldn’t use if it there are any vascular problems, any calcified vessels on the lateral X-ray, or if there are bleeding disorders, etc.”

Moderator Trousdale: “Arun or Dickey, how often when you let the tourniquet down do you have a big bleeder from the inferior lateral geniculate or the middle geniculate artery?”

Dr. Mullaji: “It’s not common, but it happens. It makes sense to deflate the tourniquet if you’re using it before you start your closure.”

Moderator Trousdale: “I’m going to take both of you to task on the cement mantle issue. Dickey, you showed the Kinamed device blowing the tibial and femoral bone nicely. And Arun, you mentioned the tourniquet in getting a good cement mantle. Do you think those differences make any clinical difference in long term durability of the total knee?”

Dr. Jones: “It does make a difference if you get better penetration. We have not been able to show that on our X-rays, however. That was done experimentally using the CarboJet system.”

Moderator Trousdale: “It may look better with the tourniquet up, but does it make a clinical difference in long term durability?”

Dr. Mullaji: “I don’t know. I don’t think there are any studies that have proven that it makes a difference, but there is the study I presented where they found the cement mantle was thicker when utilizing a tourniquet.”

Moderator Trousdale: “That’s Carsten Perka’s study…and he doesn’t use a tourniquet on his total knees.”

Dr. Jones: “A study from the American Academy of Orthopedic Surgeons showed a clear difference in the things they were measuring (in the short term).”

Moderator Trousdale: “Arun did the same study and found no difference in quad function on the two sides in patients undergoing bilateral total knees.”

Dr. Mullaji: “So I’m not convinced that it makes a difference if you use it or you don’t use it.”

Moderator Trousdale: “Thank you, gentlemen.”

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