Total Knee Replacement: To Tourniquet or Not to Tourniquet? That Is the Question!

At the 2019 Orthopaedic Summit: Evolving Technologies (OSET) held in Las Vegas this past December, two internationally-acclaimed orthopedic surgeons—Viktor Krebs, M.D., of Cleveland Clinic and Amar S. Ranawat, M.D., of Weill Cornell Medical College and Hospital for Special Surgery—squared off in a debate about how they would treat a 56-year-old marathon runner for his first total knee who requested a tourniquetless procedure, yay or nay?

First up was Viktor Krebs, M.D., who argued for the use of tourniquets. His point of view was “Pro: You Need the Tourniquet to See the Anatomy & Cement Properly.”

Dr. Krebs: In total knee replacement a tourniquet is required in order to appropriately visualize the anatomy and cement. If you are doing a tourniquetless knee, it is essentially bloodletting, which is not supported by the current literature.

The tourniquet has been used during total knee replacement since the first such procedures in 1968. Not using one means that you’re putting it up and letting your patient bleed. However, when you look at the data, patients actually don’t end up getting transfusions like you would expect and want.

Currently, tourniquets are used by up to 90% of surgeons doing total knee replacement and it’s been a clinical standard for generations. This is supported by the literature.

The tourniquet during total knee is used with the intention of minimizing intra-operative bleeding—not blood loss—improving visualization and optimizing dry bone surfaces to allow better cementing techniques.

A tourniquet makes it possible to visualize the knee in its entirety. In particular, it allows surgeons to see into the back of the knee, thus helping to ensure a solid clinical outcome.

Not using a tourniquet results in a substantial amount of blood in the field—not a situation where I would use cement. Although press fit knees work very well where blood exists, that is not an ideal bed for cementation.

Also note that a tourniquet is used with the intention of protecting your OR team from blood splatter. If you’re not using a tourniquet or if you’re using one that doesn’t work, there is blood being dispersed throughout the operating room. And if your patient has HIV or hepatitis this is an especially important consideration.

The literature reveals mixed results for actual intra-operative blood loss, the incidence of DVT [deep vein thrombosis], surgical site infection, and pain related to tourniquet use. According to the literature, tourniquet use isn’t very controversial.

I conducted a literature search from 2010 forward and found over 50 prospective studies, including roughly 25 to 26 randomized control trials, and over 15 meta-analyses of those prospective studies. I am not sure if my colleague from HSS has read these.

A randomized double-blind study of 200 patients from Rothman Orthopaedic Institute—100/100 randomized—found that tourniquet use significantly decreased blood loss and did not adversely affect postoperative functional outcomes.

Tourniquet use is safe and effective. And concerns about the deleterious effects on function and pain may not be justified.

In a JBJS article of research conducted in a Swedish rehabilitation facility, investigators reported no improved knee motion without a tourniquet. In the non-tourniquet group, they found more pain for a short period of time and no clinical relevance to improved mobility. In addition, all large meta-analyses have found no difference between postoperative pain and range of motion.

In my opinion, the duration of tourniquet use, and cuff pressure are the most important considerations. The pressures relate to the tourniquet width and thigh girth of the patient. It’s not the tourniquet—it’s the tourniquet time.

It is widely known that infection and DVT are linearly related to the length of time in surgery. Thus, the longer the tourniquet use, the larger the chance of complications.

The data will support use and non-use, but I choose to use them. Why? Because they work. It is a bloodless field and you can see what you’re doing. In conclusion, tourniquet use is safe and effective during total knee replacement and you should use it.

Next up was Amar S. Ranawat, M.D., Professor of Clinical Orthopaedic Surgery, Weill Cornell Medical College Attending Surgeon, Hospital for Special Surgery, New York, New York, who argued “I Know Why You Are Afraid, Don’t Be, No Need For The Tourniquet, Tourniquets are Dangerous.”

Dr. Ranawat: While tourniquets work, at times they are dangerous. Ideally, surgeons would know how to do surgery without them.

My opponent just said that a tourniquet “minimizes blood loss, you can see better, saves operative time, better cement technique, blah blah blah.” I agree.

But using a tourniquet too long can result in issues such as thigh pain, palsies, complications, ischemia and soft tissue damage.

So the message to my opponent is: “You’re just wrong, Viktor.”

I think Viktor read the wrong literature. The data supports me!

It’s not just about a tourniquet, it’s how you do the surgery—you must be meticulous.

I start with a spinal and use an iPack block in the knee along with IV antibiotics or tranexamic acid (TXA).

When you initially place the tourniquet, you must ensure that you don’t create a venous tourniquet as it would slow things down. I draw my incision in extension and make the incision in flexion. That’s the key—you must learn how to operate in flexion. The entire procedure needs to be done in flexion!

If I do anything in extension it takes milliseconds. Not seconds. Milliseconds.

I expose in flexion. I take the lateral meniscus out in flexion. I cauterize the lateral inferior geniculate in flexion. Then I make my cuts.

If the anesthesiologist is pumping in the blood pressure at 200, you have to turn the tourniquet up. If everyone’s working as a team, you can keep it down the whole time. Then you can do cemented or cementless—any fixation you want. But if you give a periarticular injection with epinephrine and use topical TXA, then drains are superfluous. You can do a plastic closure. You can have a field where it looks like you want it to, as opposed to the bloodbath situation that my wonderful colleague was describing.

If you wash that bone, you can do a cementless procedure. You can do anything you want. But here’s my point: doing it without a tourniquet is a technique. And in order to do it well you must do it on numerous occasions.

If you decide to go tourniquetless on a complex primary or revision or any difficult vascular path where skill is involved—you must have the ability to do it. And such skill acquisition doesn’t come overnight.

So, these are my take-home messages: The complications from using a tourniquet are well-known. But the merits of minimizing: My father, Chit Ranawat, always used to say, “Put a little rubber band on your finger. Put it on your finger and leave it there for 5 minutes, 10 minutes, 30 minutes on your finger. It hurts. It hurts bad. Right?”

If you are going to do a total knee in two hours, you had better learn how to do it tourniquetless. In every primary knee I teach my residents to learn this skill, which helps when performing complex and revision cases. Avoiding the use of a tourniquet allows the antibiotics and the TXA to go in intravenously and remain in the body for a longer period of time. I recommend the use of periarticular injections with epinephrine. And drains are unnecessary because when the procedure is finished, there is no massive blood loss.

You want to finish strong, so closure is important. Close it tight, clean, and dry. Use Dermabond or any glue.

The tourniquet is a thing of the past. Don’t be old. Be new. Be young.

You can do this Viktor!

Please visit https://orthosummit.com/ for more information on this year’s upcoming 10th Anniversary Orthopedic Summit 2020 event on December 8-12, 2020 at the Bellagio in Las Vegas, Nevada.