Total knee arthroplasties are common procedures, about 12-13 000 primary procedures are performed each year in Sweden (population 9 million). Since over 90 % of Swedish surgeons operate in a bloodless field (applying a tourniquet to the leg prior to incision), it is interesting to see research questioning our use. Could 2013 be the beginning of the end for the tourniquet in knee arthroplasties?
Tai et al showed better lab-values in the tourniquet group compared to the non-tourniquet, less drop in blood loss, less tissue trauma etc. Although interestingly there was slightly more pain after a tourniquet. My thought – what is more important lab-values or how the patient feels?
Olvecrona et al compared different pressures for the tourniquet. They used a neat photoplethysmographic sensor to measure the optimal pressure for the tourniquet. It’s a little surprising that the 164 patients randomized show any difference between the groups even though 30 % had some kind of complication. They found that pressures below 225 mmHg were not associated with complications. While this was interesting – only 1/3 of the patients were able to reach that level, even with the new cool sensor.
The last and perhaps most surprising study is by Ledin et al. They showed in 50 patients by using RSA that there was no difference in implant fixation, while at the same time noticing an increased range of motion by 10 degrees! To me the increased range of motion is rather unexpected, and although interesting the authors wisely state:
The findings regarding range of motion and pain—although highly statistically significant—should be interpreted with caution, as they were not primary variables.
In summary, three interesting studies on tourniquet use – is this the wind of change? Will we see within the next 5 years that 90 % of Swedish surgeons operate without a tourniquet? I just hope we don’t jeopardize the already amazing outcomes after total knee arthroplasties.
- T.-W. Tai, C.-W. Chang, K.-A. Lai, C.-J. Lin, and C.-Y. Yang, “Effects of Tourniquet Use on Blood Loss and Soft-Tissue Damage in Total Knee Arthroplasty A Randomized Controlled Trial,” J Bone Joint Surg Am, vol. 94, no. 24, pp. 2209–2215, Dec. 2012.
- C. Olivecrona, S. Ponzer, P. Hamberg, and R. Blomfeldt, “Lower Tourniquet Cuff Pressure Reduces Postoperative Wound Complications After Total Knee Arthroplasty A Randomized Controlled Study of 164 Patients,” J Bone Joint Surg Am, vol. 94, no. 24, pp. 2216–2221, Dec. 2012.
- H. Ledin, P. Aspenberg, and L. Good, “Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion,” Acta Orthopaedica, vol. 83, no. 5, pp. 499–503, Oct. 2012.