To tourniquet or not to tourniquet? This question has been one of the biggest controversies in the last couple of decades when it comes to total knee arthroplasty (TKA).
The tourniquet has been both praised as life-saving and condemned as limb-threatening. While tourniquets, traditionally used to reduce intraoperative blood loss and improve visualization during surgery, are still commonly used today, there have been concerns raised over whether the benefits outweigh the risks—risks like increased pain, nerve damage, ischemia or poor wound healing.
Current literature unfortunately only offers conflicting data, leaving the decision of whether to use a tourniquet or not during TKA up to each individual surgeon.
New data from Raymond Kim, M.D., an orthopedic surgeon at The Steadman Clinic, might change all that. Kim, along his colleagues, in their study, “Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial” posit that there is little benefit to using a tourniquet in surgery.
Role of Tourniquets in Surgery
Medical use of tourniquets has been around for centuries. An early version of the tourniquet was first described in a surgery treatise, Sushrata Samhita, written in 6th century BC. And in the Middle Ages it was commonly used on the battlefield during amputations to reduce pain and cut down on hemorrhaging.
In 1904, Harvey Cushing invented the pneumatic tourniquet for use in surgery, in particular to create a bloodless field for hand surgery. The pneumatic tourniquet used today in orthopedic surgeries including total knee arthroplasty allows for regulated pressure control. An inflatable tourniquet cuff inflates with air to a preset pressure to compress the patient’s blood vessels during surgical procedures.
Today most total knee arthroplasties in the United States are performed using a tourniquet despite the conflicting data on patient outcomes. According to a 2010 American Association of Hip and Knee Surgeon (AAHKS) survey, tourniquets are routinely used in 95% of primary TKA if there is no vascular compromise.
The tourniquet is thought to improve the cementation process during TKA ensuring longer implant survival but there is little available data either confirming or contradicting this.
And there are still many unanswered questions when it comes to the timing of inflation of the tourniquet, whether it should be at the beginning of the procedure or at the time of cementation, and the timing of the release of the tourniquet, before or after wound closure. Some studies have shown that releasing the tourniquet before the wound is closed increases intraoperative blood loss.
There aren’t any clear answers when it comes to total blood loss either.
Several studies have reported that there was no difference in the total blood loss between surgery with and without a tourniquet. But there have been other studies that report increased blood loss without a tourniquet. Confounding variables like whether a drain is used, also plays a role in the conflicting data. In addition, there has been limited research on the effects of tourniquet use on postoperative rehabilitation and functional recovery.
