The Tourniquetless TKA: A Miraculous Conversion

This week’s Orthopaedic Crossfire® debate was part of the 35th Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Tourniquetless TKA: A Miraculous Conversion.” For is Jose A. Rodriguez, M.D., Hospital for Special Surgery, New York, New York. Opposing is Robert E. Booth, Jr., M.D., Jefferson Health 3B Orthopaedics, Philadelphia, Pennsylvania. Moderating is Paul F. Lachiewicz, M.D., Duke University Medical Center, Durham, North Carolina.

Dr. Rodriguez: Miraculous! And yet, reluctant. I’m here to talk to you about how I got to believe what I believe.

So, why do we use a tourniquet? Because it works. It’s gives you a nice, clean surgical field. Less blood loss and reproducible cement technique. And this has been my practice for 20 years.

There are downsides. Tissue ischemia, direct pressure damage, or the embolic load that can occur with tourniquet release.

Five years into practice, my mentor Dr. Chitranjan Ranawat, started believing that tourniquets had issues. He believed in fewer tourniquets. He used tourniquets only for cementing. I resisted. This is one time that I resisted to my discredit.

After a couple of years, Dr. Amar Ranawat and I looked at our respective populations. His group comprised of only tourniquet during cementing. Mine being tourniquets from the beginning to the point when the dressing is on.

My group demonstrated that the maximum drop in hemoglobin and hematocrit was slightly higher than in the limited tourniquet groups. I felt justified. I’m preserving blood. That makes sense. Now deep in the data you also found that there were non-statistically significant increases in stiffness requiring manipulation and pulmonary embolism in my group. But that was deep in the data and before TXA [tranexamic acid], which is considered by many the modern day tourniquet.

Then there was a lovely 59-year-old female skier that I took care of two years ago. Granted, 79 minutes is a lot of tourniquet time. My opponent can do 3 knees in that time. But I obsessed trying to get the mechanics of this case right and then the mechanics were beautiful. She got great motion, but she had pain, weakness and extensor lag. After workup, we found that she had an EMG-demonstrated femoral nerve damage, most likely from the tourniquet.

And then I came to this conference and stood at this podium while Mike Meneghini described a retrospective study of 200 cases, tourniquet versus no tourniquet, demonstrating definitely marked reduction in pain and opioid use in women with no tourniquet compared to tourniquet (Kheir, et al., JOA, 2018). And given that scenario, that setting, was very meaningful to me. It made me look to figure out what the literature actually says.

In a randomized controlled trial of 70 patients—tourniquet versus no tourniquet—all around better KOOS [Knee Injury and Osteoarthritis Outcome Score] scores and range of motion at 8 weeks in the non-tourniquet group (Ejaz, Acta Orthopaedica, 2014).

In another randomized controlled trial of 81 patients, results were improved visual analog scores [VAS] for pain at 24 hours. And a persistent timed up-and-go improvement in the tourniquetless group at 3 months (Alexandersson, et al., Knee Surgery, Sports Traumatology, Arthroscopy, 2019).

What about cement penetration, you might ask? A study looked at 3 different cohorts. Tourniquet on for the entire time, or tourniquet on just for cementing, or no tourniquet at all. And they demonstrated in a randomized trial of 69 knees in each cohort, no difference in cement penetration, but a difference in terms of improved pain and knee society scores in the no-tourniquet and in the short tourniquet groups compared to the long tourniquet (Ozkunt, et al., Medicine).

Another study, randomized trial, 20 patients in each group, similarly demonstrated no difference in cement penetration in any of the planes in which it was assessed. But more importantly there was less pain in the first 4 days, and there was increased quadriceps function at 6 weeks as measured by surface EMG assessment in the no tourniquet group (Liu, et al., KSRR). This is when I said, “Okay, this is it. I’m switching.”

You can’t do this alone. In order to do this, you need your anesthesiologist and you have to take your time and get all the bleeders so that you have a nice surgical field and you don’t have to worry about them later.

Cementing does require 2 irrigations. You irrigate first and then as cement is mixed you irrigate again. We use the suction at 90 degrees and it really takes out a lot of the blood and fatty contents quite effectively, allowing an appropriate and reproducible cement interdigitation to be achieved.

I would suggest to you that using this technique, you can get reproducible cement mantles just about every single time. In my view tranexamic acid yes; tourniquet no. Because tourniquet might be good for me, but tourniquetless is better for the patient.

Dr. Booth: So first let me thank Seth for inviting a prodigal son back to the Mecca of learning here at CCJR.

I heard this story about Jose’s transformation. A miracle is an extraordinary event manifesting divine intervention in human affairs. The miracle maker, of course, is St. Michael, who is now a great friend of Jose’s.

There are other saints who have espoused this from the same podium. However, like many of our religious figures, they’re not pure. Dr. Barrack, for instance, uses a tourniquet, but only for cementing. This is a very confused issue.

Truth is almost everybody uses a tourniquet at some point. Some, like me, for the whole case. Some just for the closure. Some for cementing. Some for cementing and closure.

“Operating without a tourniquet is like fixing a watch inside an inkwell,” is an old saying from one of the founding fathers of orthopedics (Sterling Bunnell, M.D.).

However, everything Jose said is true. That there are all these minor annoying problems. But if you look at the studies he quoted, most of them are 3-month follow-up. Everything is instantaneous in our world now.

We usually go back to the meta-analysis of which there are three salient ones on this, all of which showed that time was no different for Alcelik, et al.; lower with a tourniquet for Yi, et al.; and lower with a tourniquet for Zhang, et al. And it’s that time, as well as the blood loss. Blood loss, I think, Jose would conclude is a wash.

I’m not a fan of meta-analysis. They’re usually done by somebody who’s got more time to write than operate and they mix all sorts of the literature in ways that are not necessarily enlightening. I believe in experience-based medicine.

All those complications you heard about are related to the tourniquet time. We know, from that big book that Dr. Parvizi put in your bag that infection and DVT are linearly related to the length of the surgery. So, if you’re doing an hour and a half total knee, you’re going to have 3 times the infection and DVT rate. For total knee revisions where there’s a lot of blood, most of us use a tourniquet for up to 2 hours without thinking about it. And what I never understand is if you do simultaneous bilateral knees, the second side always bleeds more. There’s something going on there we don’t understand.

For me it’s about time, predictability and the convenience of doing the surgery.

Where’s the surgeon satisfaction factor? We talk now about all these patient-related scores. I want my own Press Gainey score. I think the inmates are running the prison frankly. I want something that makes me comfortable, happy and predictable so I don’t have to worry.

I’ve known since I was a resident as Nas Eftekhar (CORR, 1975) showed with hips, that a hip socket filled with saline stuck better than one that had blood in it. I’ve believed that all my life. I’ve had a lifelong interest in picking patients who were good candidates for tourniquets because there are some issues there. Anybody with calcifications, even of the minor variety, I think, should be out of it. Certainly, the Mönckeberg’s Sclerosis (Couri, et al., BMC Cardiovasc Disord, 2005) people are definitely not candidates. People with stents, bypasses should not get tourniquets. There’s no predictive test…the ankle brachial index is not helpful. Obesity often obviates the use of a tourniquet altogether. And the worst thing of all is slow surgery.

Two of the most recent studies, which are good studies, looking at tranexamic acid versus with or without tourniquets are with surgeons who did 70- or 80-minute total knees. That’s too long for a tourniquet.

The pressure should be above systolic, and you can take an empiric number and you’d better know that your hospitals don’t calibrate those tourniquets. They come in different lengths, but few people realize they come in different widths. The pressure of the tourniquet is related to its width, not its length. If you have a fat person, you need a wider tourniquet, otherwise you’re having to apply a lot more pressure and this is a bad situation.

The game changer has been tranexamic acid. We’ve used it intravenously. Did have a little bit of an increase in pulmonary embolism rate and went to oral, which has been fine. And now our hospital is cheaping out and trying to get us to use topical. I think the answer is still out on exactly what the best combination is of that group.

Bottomline is my staff hates tourniquetless procedures. They don’t like blood in their face, and frankly they feel about the same way I do about the visibility. That’s probably what is motivating me most.

Dr. Lachiewicz: I have some questions for both of you. Jose, so do you put a tourniquet on the limb just in case, or are you totally avoiding them?

Dr. Rodriguez: I put the tourniquet on just in case. However, I haven’t inflated one in about a year.

Dr. Lachiewicz: Do you think the tourniquetless knee is viable if you don’t have a cooperative anesthesiologist?

Dr. Rodriguez: It is viable, just less reproducible.

Dr. Lachiewicz: One last question as many of us are irrigating now with either diluted betadine solution or some other types of solutions, how does that work with the tourniquetless total knee? Doesn’t that stuff wash out. Do you use that at HSS—diluted betadine?

Dr. Rodriguez: I do. The same way it works in a hip. I use them in a hip as well.

Dr. Lachiewicz: Bob, can you just reiterate for the audience the patients in which you would NOT use a tourniquet, where it’s contraindicated?

Dr. Booth: When they’re morbidly obese, especially in the thigh where the tourniquet might be. When they have calcifications. Possibly a stent. Those are the people I would avoid in general. There is no test.

Dr. Lachiewicz: Bob, what about tourniquet pressures? I know several of the residents that I work with always want to put the tourniquet up to 350 for a total knee. Do you have a parameter for that? Should it be 100 over the highest systolic? Is it 250?

Dr. Booth: Generally I use around 300. But I’m only using 20 minutes for a knee, so I don’t really feel too terrible about that. If they’re fatter, you have to put it up higher, but rather than getting the same tourniquet and raising the pressure, you really should look for those wide tourniquets. I think that’s the biggest issue in using a tourniquet properly.

Dr. Lachiewicz: Jose, I use the tourniquet except in the situations similar to those Bob has looked at it. A lot of the papers people present with the tourniquetless total knees are statistically significant, but are they really clinically important? Are you convinced that these patients are a lot better?

Dr. Rodriguez: You’re only as good as your last complication. And that one woman, where I really believe if I had not used the tourniquet, she would not have had the complications, haunts me. So, that has significantly affected how I view everything. You can do an excellent total knee without inflating the tourniquet. That’s the point.

Dr. Lachiewicz: Bob, can you recall serious complications which you feel were related to tourniquet use?

Dr. Booth: I’ve been sent two people who had femoral nerve palsies. In my own hands I’ve really not had problems with tourniquets since I learned to avoid those people we discussed. Your point is very well taken about which complications matter. I’m mindful of John Callaghan’s paper on simultaneous bilateral total knees where he had 15 complications that occurred and the conclusion was you should not do them simultaneously. When they took out everything accept DVT, infection and limb loss, the things that really mattered, suddenly it was better to do it simultaneously.

Dr. Lachiewicz: Thank you very much gentlemen. I hope this was helpful for the audience.

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