In the JournalsPerspective

Opioid consumption may be decreased with avoidance of tourniquet use in TKA

R. Michael Meneghini

Published results showed avoidance of tourniquet use may decrease opioid consumption in women undergoing total knee arthroplasty.

R. Michael Meneghini, MD, and colleagues performed a retrospective study of 203 primary unilateral cemented TKAs consecutively performed with or without tourniquet. Researchers used identical perioperative pain and blood loss protocols in all cases, and the tourniquet was not inflated at any time in the group that did not use a tourniquet. To optimize cement penetration in the group without a tourniquet, researchers used carbon dioxide compression gas (CarboJet CO2 Bone Preparation System, Kinamed Incorporated).

After controlling for multiple covariates in the 184 TKAs analyzed, investigators found significantly more pain and opioid consumption reported by women in the tourniquet group in the first 24 hours after surgery. Researchers found men who underwent TKA with or without a tourniquet had no differences in pain or in the number of opioids consumed. Both men and women who underwent TKA with a tourniquet had a significant reduction in blood loss, according to results; however, researchers noted the total blood savings of approximately 200 mL is of unknown clinical significance.

“In the modern era of opioid addiction, identifying practical methods to decrease pain and narcotic use after total knee replacement should be a goal of all surgeons and caregivers. We were pleased to discover such a dramatic decrease in inpatient opioid consumption and pain by eliminating the use of a tourniquet-induced limb ischemia,” Meneghini told Healio.com/Orthopedics. “However, we were surprised that the effect was predominantly seen in women, which underscores the need to understand pain control with an appreciation of potential gender differences. Since the discovery of these findings, we have eliminated the routine use of tourniquets in our primary total knee arthroplasty patients.” – by Casey Tingle

 

Disclosures: Meneghini reports he receives royalties from DJO and OsteoRemedies; is a paid consultant for DJO, OsteoRemedies and MuveHealth; receives stock or stock options from MuveHealth, Emovi and PixarBio; receives research support from DJO; is on the editorial or governing board for Journal of Arthroplasty and Orthopedics Today; and is a board or committee member for the American Association of Hip and Knee Surgeons Board of Directors; AAHKS Industry Relations Committee; International Congress for Joint Reconstruction Executive Board; Knee Society Membership Committee and Knee Society Research Committee. Please see the full study for a list of all authors’ relevant financial disclosures.

Editor's note: This article was updated on December 12 to add additional information on the tourniquet used in the study.

R. Michael Meneghini

Published results showed avoidance of tourniquet use may decrease opioid consumption in women undergoing total knee arthroplasty.

R. Michael Meneghini, MD, and colleagues performed a retrospective study of 203 primary unilateral cemented TKAs consecutively performed with or without tourniquet. Researchers used identical perioperative pain and blood loss protocols in all cases, and the tourniquet was not inflated at any time in the group that did not use a tourniquet. To optimize cement penetration in the group without a tourniquet, researchers used carbon dioxide compression gas (CarboJet CO2 Bone Preparation System, Kinamed Incorporated).

After controlling for multiple covariates in the 184 TKAs analyzed, investigators found significantly more pain and opioid consumption reported by women in the tourniquet group in the first 24 hours after surgery. Researchers found men who underwent TKA with or without a tourniquet had no differences in pain or in the number of opioids consumed. Both men and women who underwent TKA with a tourniquet had a significant reduction in blood loss, according to results; however, researchers noted the total blood savings of approximately 200 mL is of unknown clinical significance.

“In the modern era of opioid addiction, identifying practical methods to decrease pain and narcotic use after total knee replacement should be a goal of all surgeons and caregivers. We were pleased to discover such a dramatic decrease in inpatient opioid consumption and pain by eliminating the use of a tourniquet-induced limb ischemia,” Meneghini told Healio.com/Orthopedics. “However, we were surprised that the effect was predominantly seen in women, which underscores the need to understand pain control with an appreciation of potential gender differences. Since the discovery of these findings, we have eliminated the routine use of tourniquets in our primary total knee arthroplasty patients.” – by Casey Tingle

 

Disclosures: Meneghini reports he receives royalties from DJO and OsteoRemedies; is a paid consultant for DJO, OsteoRemedies and MuveHealth; receives stock or stock options from MuveHealth, Emovi and PixarBio; receives research support from DJO; is on the editorial or governing board for Journal of Arthroplasty and Orthopedics Today; and is a board or committee member for the American Association of Hip and Knee Surgeons Board of Directors; AAHKS Industry Relations Committee; International Congress for Joint Reconstruction Executive Board; Knee Society Membership Committee and Knee Society Research Committee. Please see the full study for a list of all authors’ relevant financial disclosures.

Editor's note: This article was updated on December 12 to add additional information on the tourniquet used in the study.

    Perspective
    Asokumar Buvanendran

    Asokumar Buvanendran

    Any modality to reduce postoperative pain management in patients undergoing knee replacement should be invigorated. Although this is a retrospective study, it provides a foundation for further prospective, randomized, controlled trials to be carried out to support the literature on the use of tourniquets for knee surgery, which has been routinely used for decades.

    No doubt, a single-surgeon group that used a current evidence-based multimodal analgesia helped reduce the pain scores. However, the most striking result is the reduced use of opioids in the first 24 hours after surgery in females. This also provokes the question whether future results should be divided by gender. 

    • Asokumar Buvanendran, MD
    • William Gottschalk endowed chair of anesthesiology
      Vice chair, research & director of orthopedic anesthesia
      Professor, department of anesthesiology
      Rush University Medical Center
      Chicago

    Disclosures: Buvanendran reports no relevant financial disclosures.