Barrack v. Lombardi: The Tourniquetless TKA: Let It Bleed

This week’s Orthopaedic Crossfire® debate was part of the 33rd Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Tourniquetless TKA: Let It Bleed.” For is Robert L. Barrack, M.D., Washington University School of Medicine, St. Louis, Missouri. Opposing is Adolph V. Lombardi, Jr., M.D., Mt. Carmel New Albany Surgical Hospital, New Albany, Ohio. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts.

Dr. Barrack: The first 25 years of my career I used a tourniquet for total knee routinely. The last several years I have not used a tourniquet. I have more confidence when I’m debating a topic on which I have extensive personal experience on both sides.

My personal observation has been that my patients are doing better clinically. It has not increased the difficulty, OR time or blood loss when I use a tourniquet in a very minimal amount when I cement. But most of my knees are cementless, so I don’t use a tourniquet at all. But that’s anecdotal and you didn’t come here to hear anecdotal data.

There’s an amazing amount of literature on this topic. The consensus is pretty strong. It’s convenient for surgeons to have a bloodless field and I do use a tourniquet for a few minutes most of the time just before I cement, but in some cases I don’t even do that.

I put it in a category of an orthopedic tradition.

Is it necessary? For lower extremity surgery where you are operating on ligaments and nerves and vessels, I could see where a bloodless field would be necessary, but for total knee, not really.

A number of traditions in knee replacement have gone by the wayside because they are not supported by evidence (CPM, drains, PCA pumps, femoral nerve blocks). Tourniquets may also be the case. An RSA study (Ejaz, et al., J Arthroplasty 2015) found that usually by the time you’re cementing the field is so dry you don’t even need to put up a tourniquet. In this study, they didn’t use a tourniquet and found no difference in implant migration.

So why not use a tourniquet? The highest-level studies show that range of motion is consistently better when a tourniquet was not used. Or if it was used, it was only used for a brief portion of cementing, which is 10 minutes, not an hour. Functional recovery and strength—Doug Dennis, one of our former Knee Society presidents, recently published a randomized trial that showed there’s more strength at 3 weeks and 3 months and he attributed this to the lack of muscle damage when you don’t use a tourniquet.

Perioperative pain. Very strong evidence in favor of not using a tourniquet in order to decrease pain postoperatively and increase recovery. Edema, swelling… studies show that the limb swells 10% from its original value, half because of return of blood, half because of reactive hyperemia.

Longer tourniquet times have been associated with increased wound drainage and decreased transcutaneous oxygen levels that slow wound healing.

We all know that when you release a tourniquet, you have a rush of embolic events and certainly embolic events are probably unavoidable, but it’s better to have them at a slow pace throughout a procedure rather than all at once for some of the older patients.

What about thromboembolic complications? Two meta-analyses, both came out strongly in favor of not using a tourniquet in order to minimize embolic complications (Tai, et al,, Knee Surg Sports Traumatol Arthrosc, 2011; Zhang, et al., J Orthop Surg Res 2014).

A very interesting study by Guler, et al. (Knee Surg Sports Traumatol Arthrosc 2016)—74 patients that had quantitative MRIs of both thighs after unilateral total knee arthroplasty with or without a tourniquet. The researchers found that there was marked atrophy when a tourniquet was used. These authors concluded that you should really be careful when you use a tourniquet and to minimize use if you use it at all.

When you use a tourniquet, intraoperative assessment is compromised. Patella tracking, range of motion, ligament stability and it complicates IV drug use. If you look at all the randomized clinical trials, they favor not using a tourniquet. Occasionally they will say that the results are equal, but if there is a difference, it always favors going tourniquetless. Same with the meta-analyses.

The AAOS has released guidelines for surgical management of osteoarthritis and they state there is strong evidence, the highest level, 4 stars, of less pain when you don’t use a tourniquet.

Where did tourniquets come from? They were used in the battlefield in the Civil War. They probably saved thousands of lives. They were used for battlefield amputations. In the last decade, the U.S. Special Forces Command mandates the issuance of tourniquets to our combat forces. But for combat wounds and urgent vascular injury, the benefit of the dramatic tissue damage exceeds a risk, but for total knee arthroplasty it does not.

Dr. Lombardi:

As you heard, a tourniquet controls bleeding from amputations and it may actually save a life. I know the term was coined by a Frenchman—Jean Louis Petit—I had a French fellow who told me I should be saying “turnakey.”

Today, tourniquets are used about 15,000 times a day.

Some people don’t use a tourniquet. Others use the tourniquet only for the exposure. Robert uses the tourniquet for cementation. I like to release the tourniquet after I cement. And then we have people who release after closure.

But, they all use tourniquets.

We know exactly what we’re doing when we use tourniquets. It is part of the routine.

Position the patient, give them antibiotics, put the tourniquet on, figure out what pressure, prep, drape, time out and then do your surgery.

What are the advantages? Why do I use it?

It enhances my visibility. There is less blood while I’m cementing. Less intraoperative blood loss—and I agree with Robert that overall there’s no significant difference—total blood loss or transfusion. I do believe that tourniquets help me focus on exactly where I’m putting those components and making sure that I get proper alignment, and proper balance, etc.

We learned over 20 years ago less blood and fat, better interdigitation, better penetration, lavage and have a nice dry field for longer term survivorship.

There is a danger. If it’s used improperly and for too long or at too high of a pressure, we can see some neurological injury. Robert’s absolutely correct. There is a lot of literature on this and it might sway you to think that you shouldn’t use a tourniquet. There is a significant decrease in intraoperative blood loss; non-significant differences in total blood loss and transfusions and an increased trend towards wound hematomas, DVTs, and wound healing disorders.

A meta-analysis by Alcelik, et al. (J Arthroplasty 2012) looked at outcomes—minor complications were more common with a tourniquet, but there was no difference for operative time, DVT / PE and major complications. The total and intraoperative blood loss was less with the tourniquet.

Another meta-analysis looking at 13 papers (Yi, et al., AOTS 2014). Significant decrease in the operative time, intraoperative blood loss and total blood loss, but a significant increase in postoperative blood loss. No significant increase in DVT or infection.

Another one (Zhang, et al., J Orthop Surg Res 2014). Significant reduction in intraoperative blood loss and operative time. No reduction in transfusions. Range of motion decreased; thrombotic events increased. And minor complications increased.

There’s no free lunch. As we learned from Doug Dennis (CORR 2015), there’s decrease in surgery time, lower intraoperative blood loss, but a higher total blood loss. Maybe DVT. And slightly lower extremity strength out to about 3 months.

I think the other thing is the timing of release. So, how long do you leave it up and when do you let it down? If you let it down earlier, there was a significant increase in total blood loss and drop in hemoglobin. But reoperations due to postoperative complications were much less in the earlier release versus the late release (Rama, et al., JBJS 2007).

Another reason to release the tourniquet after cementation is to assess patellofemoral tracking and I’ve published on this topic and found a 69% reduction in indication for lateral retinacular release.

My take-home message to you is that I use a tourniquet because it does help me get a better exposure. It does help me visualize the bony landmarks. It does help me implant the device correctly.

It facilitates my focus on the proper positioning of components and it facilitates the cementing technique. And, I think at the end of the day, none of those RCTs really gave me any information about timing. So, if you can do your operation efficiently, I believe use of the tourniquet is definitely a thing to do.

Moderator Thornhill: Okay, let me ask the audience. How many people routinely use a tourniquet when they do a total knee? About 220. How many of those who use a tourniquet now think that they might consider NOT using a tourniquet after what you’ve heard? So that’s more…. That’s very interesting.

Adolph, you said something that is quite correct. It all depends on how much and how long. My question is “How much and how long, and how much time in between?”

Dr. Lombardi: You don’t need to on every patient put that tourniquet up at 350-400. Look at the size of the leg; look at the pressure. Some devices are smart, and they can actually tell you what pressure you need to put it at. The literature says that you should leave the tourniquet up for more than 2 hours. But, I don’t take 2 hours to do a total knee, so our tourniquet times are pretty short.

Moderator Thornhill: How much pressure in an average person? 250? 300? Does systolic pressure make any difference?

Dr. Lombardi: Yeah, I generally do about 250-300 in an average limb and when I get the real bulky limb we go up to 375-400.

Moderator Thornhill: So let’s say you’ve got somebody with Mönckeberg sclerosis—the really sort of calcified vessel—and you put it up to 400…

Dr. Lombardi: I don’t put a tourniquet on that patient. If they have any peripheral vascular disease, if there’s any indication from my internist that maybe we shouldn’t use a tourniquet, we don’t use a tourniquet for that patient. And it’s a miserable day for me.

Moderator Thornhill: Robert, blood loss.

Dr. Barrack: I may have a skewed view because I stopped using a tourniquet the same time we started using TXA [tranexamic acid] but that’s been 5 years. And I was pleasantly surprised that after the first 5 minutes of the case, when you flex the knee and start your bone cut…all the residents and fellows are amazed by how little blood they’re looking at.

Moderator Thornhill: I think if you look at the whole episode, it’s been shown that overall blood loss may occur at different times, but the overall blood loss is roughly the same. Is that true, Adolph?

Dr. Lombardi: That’s true. I think the literature is pretty clear on that. The overall blood loss is about the same whether you use a tourniquet or not. To me …I’ve tried it and it’s a bloody mess.

Moderator Thornhill: I generally have the tourniquet put up for the first 5 minutes of opening and then let it down. I am not sure I get a hyperemia, but in flexion it doesn’t seem to bleed. I usually use it for cementing, but not always. When I do a uni, since I extend the knee and flex the knee a fair amount, I use a tourniquet.

Great debate is one that generates a lot of questions. I want to thank everyone, the audience for being here.

Please visit www.CCJR.com to register for the 2018 CCJR Winter Meeting, – December 12 – 15 in Orlando.