Tourniquet use in knee surgery: is it time to move on?

Appropriate tourniquet use in surgery: A literature review

BACKGROUND

Tourniquet use is ubiquitous in the operating theatre. However, optimal tourniquet usage is unclear, including type, pressure, inflation time, or whether a tourniquet should be used at all. This study reports a literature review of tourniquet use, comparing type, pressure, duration, effectiveness, and the spectrum of complications in an adult surgical population.

RESULTS

Data regarding population size, surgery performed, tourniquet type, tourniquet location, total tourniquet inflation time, timing of inflation and deflation, pressure, and complications were recorded. Postoperative tourniquet-related pain was the commonest adverse event. Other complications included venous thromboembolism, wound healing issues, neuropathy, and abrasions. Findings suggest that most surgeons use standardised pressures.

CONCLUSION

Tourniquets are associated with a spectrum of complications. It is unclear whether tourniquet use provides better surgical outcomes. If tourniquets are used, surgeons should minimise the application pressure and duration. This may be achieved through a patient-centred approach and careful use of padding.

Tourniquet use in patients undergoing tumour resection and endoprosthetic reconstruction of the knee

AIMS

The aim of this study was to determine the prevalence and impact of tourniquet use in patients undergoing limb salvage surgery with endoprosthetic reconstruction for a tumour around the knee.

METHODS

We retrieved data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial; specifically, differences in baseline characteristics, surgical details, and postoperative functional outcomes between patients who had undergone surgery under tourniquet and those who had not. A linear regression model was created to evaluate the impact of tourniquet use on postoperative Toronto Extremity Salvage Scores (TESSs) while controlling for confounding variables. A negative-binomial regression model was constructed to explore predictors of postoperative length of stay (LOS).

RESULTS

Of the 604 patients enrolled in the PARITY trial, 421 had tumours around the knee joint, of whom 225 (53%) underwent surgery under tourniquet. The tourniquet group was younger (p = 0.014), more likely to undergo surgery for a tumour of the tibia, and had shorter operating times by a mean of 50 minutes (95% confidence interval 30 to 72; p < 0.001). The adjusted linear regression model found that the use of a tourniquet, a shorter operating time, and a higher baseline TESS independently predicted better function at both three- and six-month follow-up. The negative-binomial regression model showed that tourniquet use, shorter operating time, younger age, and intraoperative tranexamic acid administration independently predicted a shorter LOS in hospital.

CONCLUSION

The results of this study show that in patients undergoing resection of a tumour around the knee and endoprosthetic reconstruction, the use of an intraoperative tourniquet is associated with a shorter operating time, a reduced length of stay in hospital, and a better early functional outcome.Cite this article: Bone Joint J 2022;104-B(10):1168-1173.

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

Purpose

The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA.

Methods

A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate.

Results

14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7–5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1–3.1) with an OR of 1.9 (95% CI = 1.1–3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12–0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4–5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10–0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7–9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50–19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60–3.60, p = 0.36) did not differ between the two groups.

Conclusion

Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use.

Level of evidence

meta-analysis, Level II.

Effects of the Femoral Nerve Block and Adductor Canal Block on Tourniquet Response and Postoperative Analgesia in Total Knee Arthroplasty

Tourniquet has emerged as an important role in surgical procedures, sixty patients undergoing elective total knee arthroplasty are randomly divided into the nerve block group and adductor duct block group in this paper. The changes of mean arterial pressure (MAP) and heart rate (HR) at different time points during operation, the changes of VAS scores at resting pain and exercise pain, and the changes of quadriceps femur muscle strength at different time points after operation are observed in 2 groups. The experimental results show that compared with adductor duct block, femoral nerve block can better relieve the intraoperative tourniquet reaction without affecting the postoperative analgesic effect and the muscle strength of quadriceps femurs.