J Knee Surg 2020; 33(10): 987-991
DOI: 10.1055/s-0039-1688919
Original Article

Impact of Tourniquet Strategy on Perioperative Results of Modern TKA

Richard D. Rames
1   Department of Orthopaedic Surgery, Washington University in St. Louis, Barnes-Jewish Hospital, St. Louis, Missouri
,
Jacob Haynes
1   Department of Orthopaedic Surgery, Washington University in St. Louis, Barnes-Jewish Hospital, St. Louis, Missouri
,
Michael Hellman
1   Department of Orthopaedic Surgery, Washington University in St. Louis, Barnes-Jewish Hospital, St. Louis, Missouri
,
Toby Barrack
1   Department of Orthopaedic Surgery, Washington University in St. Louis, Barnes-Jewish Hospital, St. Louis, Missouri
,
Robert Barrack
1   Department of Orthopaedic Surgery, Washington University in St. Louis, Barnes-Jewish Hospital, St. Louis, Missouri
› Author Affiliations
Funding None.

Abstract

Recent changes in perioperative management of total knee patients including tranexamic acid, multimodal pain management, and periarticular injection make previous data on tourniquet use during total knee arthroplasty (TKA) less relevant. The purpose of this study was to evaluate the effect of tourniquet use on short-term postoperative outcomes in the era of modern TKA. Our institutional database was utilized to retrospectively identify three cohorts (long, short, and no tourniquet) of consecutive patients after unilateral TKA with a single surgeon. These three groups were compared using analysis of variance (ANOVA) and post hoc Tukey's tests. Primary endpoints being hemoglobin index (difference in preoperative and postoperative hemoglobin), inpatient narcotic use, surgical time, length of hospital stay (total hours and % day1 discharges), and distance ambulated prior to discharge. The no-tourniquet group used significantly less narcotic than the short-tourniquet (2.4 vs. 2.9 morphine equivalent/hour, p = 0.004) and long-tourniquet groups (2.4 vs. 3.4 morphine equivalents/hour, p < 0.001). The no-tourniquet group ambulated significantly further than patients in the short (108 vs. 57 feet, p < 0.001) and long (108 vs. 76 feet, p < 0.001) groups. Finally, the no-tourniquet group had significantly shorter duration of hospitalization than the long-tourniquet group in both hours in the hospital (35 vs. 57 hours, p < 0.001) and % postoperative day 1 discharge (57 vs. 12%, p < 0.001). TKA without the use of a tourniquet is associated with less narcotic consumption and increased distance ambulated prior to discharge compared with cohorts of patients utilizing tourniquet for a short or long duration.



Publication History

Received: 02 November 2018

Accepted: 05 April 2019

Article published online:
20 May 2019

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 
  • References

  • 1 Berry DJ, Bozic KJ. Current practice patterns in primary hip and knee arthroplasty among members of the American Association of Hip and Knee Surgeons. J Arthroplasty 2010; 25 (6, Suppl.): 2-4
  • 2 Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee 2010; 17 (02) 141-147
  • 3 Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P. A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty 2012; 27 (03) 331-340
  • 4 Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2011; 19 (07) 1121-1130
  • 5 Dennis DA, Kittelson AJ, Yang CC, Miner TM, Kim RH, Stevens-Lapsley JE. Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res 2016; 474 (01) 69-77
  • 6 Chen S, Li J, Peng H, Zhou J, Fang H, Zheng H. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. Int Orthop 2014; 38 (02) 355-359
  • 7 Ejaz A, Laursen AC, Kappel A. , et al. Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop 2014; 85 (04) 422-426
  • 8 Ejaz A, Laursen AC, Kappel A, Jakobsen T, Nielsen PT, Rasmussen S. Tourniquet induced ischemia and changes in metabolism during TKA: a randomized study using microdialysis. BMC Musculoskelet Disord 2015; 16: 326
  • 9 Boonstra RH, Haverkamp D, Campo MM, van der Vis HM. Acute compartment syndrome of the thigh following total knee arthroplasty. Knee 2012; 19 (02) 151-153
  • 10 Heller S, Chen A, Restrepo C, Albert E, Hozack WJ. Tourniquet release prior to dressing application reduces blistering following total knee arthroplasty. J Arthroplasty 2015; 30 (07) 1207-1210
  • 11 Kumar N, Yadav C, Singh S, Kumar A, Vaithlingam A, Yadav S. Evaluation of pain in bilateral total knee replacement with and without tourniquet; a prospective randomized control trial. J Clin Orthop Trauma 2015; 6 (02) 85-88
  • 12 Liu D, Graham D, Gillies K, Gillies RM. Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. Knee Surg Relat Res 2014; 26 (04) 207-213
  • 13 Nadeem RD, Clift BA, Martindale JP, Hadden WA, Ritchie IK. Acute compartment syndrome of the thigh after joint replacement with anticoagulation. J Bone Joint Surg Br 1998; 80 (05) 866-868
  • 14 Silver R, de la Garza J, Rang M, Koreska J. Limb swelling after release of a tourniquet. Clin Orthop Relat Res 1986; (206) 86-89
  • 15 Smith PN, Rampersaud R, Rorabeck CH. Incipient compartment syndrome of the thigh following total knee arthroplasty. J Arthroplasty 1997; 12 (07) 835-838
  • 16 Pinheiro AA, Marques PM, Sá PM, Oliveira CF, da Silva BP, de Sousa CM. Compartment syndrome after total knee arthroplasty: regarding a clinical case. Rev Bras Ortop 2015; 50 (04) 478-481
  • 17 Olivecrona C, Blomfeldt R, Ponzer S, Stanford BR, Nilsson BY. Tourniquet cuff pressure and nerve injury in knee arthroplasty in a bloodless field: a neurophysiological study. Acta Orthop 2013; 84 (02) 159-164
  • 18 Olivecrona C, Ponzer S, Hamberg P, Blomfeldt R. Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty: a randomized controlled study of 164 patients. J Bone Joint Surg Am 2012; 94 (24) 2216-2221
  • 19 Zhang W, Liu A, Hu D, Tan Y, Al-Aidaros M, Pan Z. Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 2014; 9: 125
  • 20 Pfitzner T, von Roth P, Voerkelius N, Mayr H, Perka C, Hube R. Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24 (01) 96-101
  • 21 Ejaz A, Laursen AC, Jakobsen T, Rasmussen S, Nielsen PT, Laursen MB. Absence of a tourniquet does not affect fixation of cemented TKA: a randomized RSA study of 70 patients. J Arthroplasty 2015; 30 (12) 2128-2132
  • 22 Mori N, Kimura S, Onodera T, Iwasaki N, Nakagawa I, Masuda T. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: a prospective, randomized study. Knee 2016; 23 (05) 887-889
  • 23 Matsubara J, Narumi J, Nagasue M, Sakamoto S, Yuasa K, Shimizu T. Postocclusive reactive hyperemia during vascular reconstruction. Int J Angiol 1998; 7 (03) 222-227
  • 24 Kubli S, Waeber B, Dalle-Ave A, Feihl F. Reproducibility of laser Doppler imaging of skin blood flow as a tool to assess endothelial function. J Cardiovasc Pharmacol 2000; 36 (05) 640-648
  • 25 Schnettler T, Papillon N, Rees H. Use of a tourniquet in total knee arthroplasty causes a paradoxical increase in total blood loss. J Bone Joint Surg Am 2017; 99 (16) 1331-1336
  • 26 Kheir MM, Ziemba-Davis M, Dilley JE, Hood Jr. MJ, Meneghini RM. Tourniquetless total knee arthroplasty with modern perioperative protocols decreases pain and opioid consumption in women. J Arthroplasty 2018; 33 (11) 3455-3459
  • 27 Fan Y, Jin J, Sun Z. , et al. The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. Knee 2014; 21 (06) 1263-1268
  • 28 Ishii Y, Matsuda Y. Effect of the timing of tourniquet release on perioperative blood loss associated with cementless total knee arthroplasty: a prospective randomized study. J Arthroplasty 2005; 20 (08) 977-983
  • 29 Akizuki S, Yasukawa Y, Takizawa T. A new method of hemostasis for cementless total knee arthroplasty. Bull Hosp Jt Dis 1997; 56 (04) 222-224
  • 30 Younger AS, McEwen JA, Inkpen K. Wide contoured thigh cuffs and automated limb occlusion measurement allow lower tourniquet pressures. Clin Orthop Relat Res 2004; (428) 286-293