The Steadman Clinic’s Kim: Tourniquetless TKA Superior

To tourniquet or not to tourniquet? This question has been one of the biggest controversies in the last couple of decades when it comes to total knee arthroplasty (TKA).

The tourniquet has been both praised as life-saving and condemned as limb-threatening. While tourniquets, traditionally used to reduce intraoperative blood loss and improve visualization during surgery, are still commonly used today, there have been concerns raised over whether the benefits outweigh the risks—risks like increased pain, nerve damage, ischemia or poor wound healing.

Current literature unfortunately only offers conflicting data, leaving the decision of whether to use a tourniquet or not during TKA up to each individual surgeon.

New data from Raymond Kim, M.D., an orthopedic surgeon at The Steadman Clinic, might change all that. Kim, along his colleagues, in their study, “Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial” posit that there is little benefit to using a tourniquet in surgery.

Role of Tourniquets in Surgery

Medical use of tourniquets has been around for centuries. An early version of the tourniquet was first described in a surgery treatise, Sushrata Samhita, written in 6th century BC. And in the Middle Ages it was commonly used on the battlefield during amputations to reduce pain and cut down on hemorrhaging.

In 1904, Harvey Cushing invented the pneumatic tourniquet for use in surgery, in particular to create a bloodless field for hand surgery. The pneumatic tourniquet used today in orthopedic surgeries including total knee arthroplasty allows for regulated pressure control. An inflatable tourniquet cuff inflates with air to a preset pressure to compress the patient’s blood vessels during surgical procedures.

Today most total knee arthroplasties in the United States are performed using a tourniquet despite the conflicting data on patient outcomes. According to a 2010 American Association of Hip and Knee Surgeon (AAHKS) survey, tourniquets are routinely used in 95% of primary TKA if there is no vascular compromise.

The tourniquet is thought to improve the cementation process during TKA ensuring longer implant survival but there is little available data either confirming or contradicting this.

And there are still many unanswered questions when it comes to the timing of inflation of the tourniquet, whether it should be at the beginning of the procedure or at the time of cementation, and the timing of the release of the tourniquet, before or after wound closure. Some studies have shown that releasing the tourniquet before the wound is closed increases intraoperative blood loss.

There aren’t any clear answers when it comes to total blood loss either.

Several studies have reported that there was no difference in the total blood loss between surgery with and without a tourniquet. But there have been other studies that report increased blood loss without a tourniquet. Confounding variables like whether a drain is used, also plays a role in the conflicting data. In addition, there has been limited research on the effects of tourniquet use on postoperative rehabilitation and functional recovery.

Tourniquet’s Effect on Patient Recovery

Kim and his colleagues wanted to explore in more detail how tourniquet use in TKA affects the recovery of lower extremity strength and function.

According to Kim, the potential disadvantages of tourniquet use include reduced early TKA flexion, increased perioperative pain and increased lower extremity edema. There is also an increase in wound complications, cardiac and cerebral micro-emboli, arterial thrombosis, particularly in patients with peripheral vascular disease, as well as increase in deep vein thrombosis and peripheral nerve injury. Reduction in antibiotic circulation to surgical site is also a concern.

He said, “Ours is the first prospectively randomized study to analyze effects of tourniquet use on quantitative quadriceps strength following primary TKA. When we were starting our study, I actually put a tourniquet on my thigh and tried to put it up for ten minutes and after ten minutes I couldn’t tolerate this anymore and the next day I had trouble walking up and down the stairs so we knew that there was something to this particular study in terms of pain and quad function.”

In this prospectively randomized study, Kim and colleagues evaluated recovery of quadriceps strength and lower extremity function following primary TKA and evaluated secondary factors like blood loss, post-op pain and lower extremity edema.

Kim and his colleagues enrolled 28 patients undergoing bilateral primary TKA in the study (16 males and 12 females) and were randomized to either the tourniquet or no tourniquet group. All of them were diagnosed with osteoarthritis. The mean age was 61 years, mean BMI (body mass index) 28.6 kg/m².

In the non-tourniquet group, however, 64% of them did have a tourniquet on for the cementing process for a mean tourniquet time of 8.93 minutes.

Kim said that he chose the bilateral TKA model because it limits confounding variables in regards to demographic differences and medical co-morbidities.

The surgical team did the bilateral TKAs at the same OR intervention and sequentially. They implanted the same components into each knee via medial peripatellar approach. They used gap balancing technique and cemented all knees. In addition, the operative team recorded all tourniquet times and intraoperative and postoperative blood loss. And they made sure that the same physical therapy protocol was instituted for all patients at the University of Colorado, Anschutz Medical Campus.

The study investigators tested their patients preoperatively and then postoperatively on day 2, at 3 weeks and at 3 months and collected data that included isometric quad torque, which was the primary outcome and was measured using the electromechanical dynamometer.

They also employed the quadriceps activation test using the doublet interpolation test as well as the unilateral balance test. And they measured active TKA range of motion, lower extremity edema, perioperative pain and blood loss intra-operatively and post-operatively.

According to the data, there was no statistical differences between knees in terms of perioperative measures. Tourniquet time for the tourniquet group was 50.63 (11.35) minutes and 8.93 (5.74) minutes for the no tourniquet group (p < 0.001). Operative time for the tourniquet group was 61.88 (10.77) minutes, and 64.88 (9.48) minutes for the no tourniquet group (p = 0.22)

When it came to intraoperative blood loss, the tourniquet group lost 83.92 (25.85) ml compared to the no tourniquet group which lost 155.77 (62.57) ml (p < 0.001). Total blood loss was 426.53 (197.50) ml for the tourniquet group and 562.94 (340.96) ml for the no tourniquet group (p = 0.13).

Kim and his team found no difference in knee flexion or extension nor in calf, knee, and thigh girth in regards to edema. Regarding quad strength there was definite superior results in the no tourniquet group both at 3 weeks and at 3 months.

Interestingly enough, Kim said, there was no difference in regards to hamstring strength. In regards to quad activation, there was no statistical difference, but there was a trend at 3 weeks favoring the no tourniquet group.

Regarding unilateral balance, he also said there was no statistical difference but there was a trend at 3 weeks and 3 months favoring the no tourniquet group. And in regards to postoperative pain, the non-tourniquet group had less pain at 3 weeks.

Kim acknowledged certain limitations of the study like that the sample size might be inadequate to evaluate all the variables and the fact that even a majority of patients in the non-tourniquet group had a tourniquet used for the cementing process.

Putting It in Context

Most studies confirm what Kim and his colleagues found which was increased intraoperative blood loss. But there are also many studies that show no difference so the literature is conflicting. There can also be some hidden blood loss, some blood in the knee joint, extravasation into soft tissues.

Some studies found that if a tourniquet was used there could be blood loss due to ischemia with prolonged hyperemia which could increase bleeding.

In regards to postoperative pain, there have also been similar reports of early increased postoperative pain with tourniquet use. Increased post-operative pain was also associated with increased tourniquet inflation pressure and tourniquet duration. In Kim’s study, pain was still present at 3 weeks post-op.

Kim said, “The reasons for this increased pain include direct muscle fiber damage, ischemia-induced muscle fiber necrosis and ischemia due to increased chemical induced soft tissue inflammation.”

“Overall in our study,” Kim said, “We found that tourniquet use negatively impacts quad strength at 3 months and results in more post-op pain at 3 weeks following TKA and because of this evidence there is limited tourniquet use at our institution.”

Meet Dr. Kim at the Upcoming ICJR South Hip and Knee Course

This study was originally published in the January 2016 issue of Clinical Orthopaedics and Related Research and presented at the International Congress for Joint Reconstruction’s 2016 4th Annual South Hip and Knee Course. At the time of the original presentation, Kim was a surgeon at the Colorado Joint Replacement Porter Adventist Hospital in Denver, Colorado.

Kim’s presentation on Tourniquetless TKA is also on the agenda for the 6th Annual International Congress for Joint Reconstruction South Hip & Knee Course which will be held June 21-23, 2018 in Key Largo, Florida, at the Ocean Reef Club.

The conference is designed for orthopedic surgeons and allied health professionals looking to learn the latest in orthopedic technology, surgical technique and optimum patient care. The course will include current controversies in TKA and total hip arthroplasty, enhanced recovery and outpatient arthroplasty, live surgery and perioperative patient management.

To register, click here.