Meeting News

Surgery without tourniquet may prove advantageous vs tourniquet use

Patient selection is key when using a tourniquet, but specific practices may improve tourniquetless surgery

 
Jose A. Rodriguez
 
Robert E. Booth Jr.

Although tourniquet use during surgery has its advantages, presenters at a meeting noted in some cases it may do more harm than good.

“Why do we use a tourniquet? We use it because it works. It gives you a nice, clean surgical field, less blood loss and reproducible cement technique, and this has been my practice for 20 years,” Jose A. Rodriguez, MD, hip and knee surgeon at Hospital for Special Surgery, said at the Current Concepts in Joint Replacement Winter. “But let’s be clear: There are downsides, whether it is tissue ischemia, direct pressure damage or the embolic load that occurs with tourniquet release.”

Tourniquet vs no tourniquet

Although Rodriguez found a maximum drop in hemoglobin and a slightly higher hematocrit in his patients with limited tourniquet use, on closer examination he found non-statistically significant increases in pulmonary embolism, as well as stiffness that required manipulation.

Nerve damage has also been associated with tourniquet use for long periods of time, Rodriguez noted.

“All those complications … are related to the tourniquet times and we know … that infection and [deep vein thrombosis] DVT are linearly related to the length of the surgery,” Robert E. Booth Jr., MD, said. “If you are doing an hour-and-a-half total knee, you are going to have three times the infection and DVT rate as a half-hour procedure.”

Published studies in which tourniquet use was compared to no tourniquet use showed a marked reduction in pain and opioid use, better KOOS scores and range of motion, and improved VAS for pain and timed up and go test scores for the no tourniquet group, according to Rodriguez.

In cemented total knee arthroplasty cases, Rodriguez said the literature has shown patients who received no tourniquet, or a tourniquet used during cementing only, had no differences in cement penetration compared with when a tourniquet was used during the entire TKA procedure. However, patients experienced improved pain and Knee Society Scores with no tourniquet or with a tourniquet used during cementing only.

Advice for tourniquet use

Booth noted patient selection is important when using a tourniquet. Patients with calcifications, Monckeberg sclerosis and patients with stents or bypasses are not good candidates for tourniquet use, he said.

“There is 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 a slow surgery,” Booth said.

Although surgeons know tourniquets come in different lengths, Booth said few of them “realize they come in different widths, and so the pressure of a tourniquet is related more to its width than its length.”

Rodriguez suggested surgeons should have anesthesiologists provide a systolic blood pressure of less than 90 mm Hg and most of the surgery should be performed with the knee in flexion when a tourniquet is not used. When using cement, irrigation should be performed both before and after the cement is mixed, according to Rodriguez.

“We use the suction at 90° and it takes out a lot of the blood and fatty contents quite effectively allowing an appropriate and reproducible cement interdigitation to be achieved,” Rodriguez said. “I would suggest that using this technique, you can get reproducible cement mantles just about every single time with no difference —tourniquet vs. [no] tourniquet.” – by Casey Tingle

References:

Booth, RE Jr. Paper 64. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2018; Orlando.

Rodriguez JA. Paper 63. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2018; Orlando.

For more information:

Robert E. Booth, Jr., MD, can be reached at Jefferson Health, 3B Orthopaedics, 601 Walnut St., Suite L50, Philadelphia, PA 19106.

Jose A. Rodriguez, MD, can be reached at 541 E. 71st St., New York, NY 10021; email: ironsm@hss.edu.

Disclosures: Rodriguez reports he receives consulting fees and royalties for consulting and design from Conformis, Exactech, Medacta International SA and Smith & Nephew. Booth reports no relevant financial disclosures.

 
Jose A. Rodriguez
 
Robert E. Booth Jr.

Although tourniquet use during surgery has its advantages, presenters at a meeting noted in some cases it may do more harm than good.

“Why do we use a tourniquet? We use it because it works. It gives you a nice, clean surgical field, less blood loss and reproducible cement technique, and this has been my practice for 20 years,” Jose A. Rodriguez, MD, hip and knee surgeon at Hospital for Special Surgery, said at the Current Concepts in Joint Replacement Winter. “But let’s be clear: There are downsides, whether it is tissue ischemia, direct pressure damage or the embolic load that occurs with tourniquet release.”

Tourniquet vs no tourniquet

Although Rodriguez found a maximum drop in hemoglobin and a slightly higher hematocrit in his patients with limited tourniquet use, on closer examination he found non-statistically significant increases in pulmonary embolism, as well as stiffness that required manipulation.

Nerve damage has also been associated with tourniquet use for long periods of time, Rodriguez noted.

“All those complications … are related to the tourniquet times and we know … that infection and [deep vein thrombosis] DVT are linearly related to the length of the surgery,” Robert E. Booth Jr., MD, said. “If you are doing an hour-and-a-half total knee, you are going to have three times the infection and DVT rate as a half-hour procedure.”

Published studies in which tourniquet use was compared to no tourniquet use showed a marked reduction in pain and opioid use, better KOOS scores and range of motion, and improved VAS for pain and timed up and go test scores for the no tourniquet group, according to Rodriguez.

In cemented total knee arthroplasty cases, Rodriguez said the literature has shown patients who received no tourniquet, or a tourniquet used during cementing only, had no differences in cement penetration compared with when a tourniquet was used during the entire TKA procedure. However, patients experienced improved pain and Knee Society Scores with no tourniquet or with a tourniquet used during cementing only.

Advice for tourniquet use

Booth noted patient selection is important when using a tourniquet. Patients with calcifications, Monckeberg sclerosis and patients with stents or bypasses are not good candidates for tourniquet use, he said.

“There is 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 a slow surgery,” Booth said.

Although surgeons know tourniquets come in different lengths, Booth said few of them “realize they come in different widths, and so the pressure of a tourniquet is related more to its width than its length.”

Rodriguez suggested surgeons should have anesthesiologists provide a systolic blood pressure of less than 90 mm Hg and most of the surgery should be performed with the knee in flexion when a tourniquet is not used. When using cement, irrigation should be performed both before and after the cement is mixed, according to Rodriguez.

“We use the suction at 90° and it takes out a lot of the blood and fatty contents quite effectively allowing an appropriate and reproducible cement interdigitation to be achieved,” Rodriguez said. “I would suggest that using this technique, you can get reproducible cement mantles just about every single time with no difference —tourniquet vs. [no] tourniquet.” – by Casey Tingle

References:

Booth, RE Jr. Paper 64. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2018; Orlando.

Rodriguez JA. Paper 63. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2018; Orlando.

For more information:

Robert E. Booth, Jr., MD, can be reached at Jefferson Health, 3B Orthopaedics, 601 Walnut St., Suite L50, Philadelphia, PA 19106.

Jose A. Rodriguez, MD, can be reached at 541 E. 71st St., New York, NY 10021; email: ironsm@hss.edu.

Disclosures: Rodriguez reports he receives consulting fees and royalties for consulting and design from Conformis, Exactech, Medacta International SA and Smith & Nephew. Booth reports no relevant financial disclosures.

    Perspective

    The literature reveals mixed results for actual intraoperative blood loss, incidence of DVT, surgical site infection and pain related to tourniquet use. Are the results truly mixed or are there patient-specific variables that still need to be teased out? In the era of personalized medicine, we should consider tailoring our surgery based on patient factors, thus weighing the potential benefits and risks of all aspects of the surgery, including conventional tourniquet use.

    With respect to pain, our group recently published a paper on narcotic consumption comparing tourniquet vs. tourniquetless TKA cases in 184 consecutive patients. After controlling for multiple covariates, women in the tourniquet group reported more pain and used more opioids in the first 24 hours postoperatively compared to the tourniquetless group. Men who underwent TKA had no differences in pain or opioid consumption regardless of tourniquet application. This is a highly relevant topic at this time given the growing attention on opioid addiction. Our study illustrates that careful patient selection for tourniquet use is critical. While the gender differences in these results are not yet fully understood, avoiding tourniquet use during TKA for females may be one example of a relatively risk-free and practical method to decrease opioid consumption during hospitalization.

    Reference:

    Kheir MM, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.06.038.

    • Michael M. Kheir, MD
    • Department of orthopedic surgery
      Indiana University School of Medicine
      Indianapolis

    Disclosures: Kheir reports no relevant financial disclosures.

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