When most people undergo knee replacement, a tourniquet is used during the surgery. For any of you who do not know, a tourniquet is a device that wraps around the leg and use pneumatic pressure to squeeze on the leg and prevent blood flow to the rest of the extremity.
In the case of a knee replacement, the tourniquet is placed on the thigh so that no blood reaches the knee during the surgery. It is not unusual to use a tourniquet in extremity surgery. In fact, tourniquets have been used in total knee replacement surgery since the inception of the procedure.
While this is standard practice, some of us have stared asking if it is the best thing for our patients.
What are the advantages of using a tourniquet?
Surgeons choose to use tourniquets for a reason. The primary advantage during knee replacement surgery is visualization. The tourniquet prevents blood flow to the knee making it easier for the surgeon to see.
Another potential advantage is a decrease in blood loss during the surgery. The idea of decreased blood loss, however, turns out not be completely true. While a tourniquet decreases blood loss during the surgery, patients who have the surgery with a tourniquet end up having just as much blood loss as those who didn’t have a tourniquet. The difference is that the blood loss happens in the knee after the surgery and after the wound has been closed.
Other than visualization, there are no other advantages.
What are the disadvantages of using a tourniquet?
As you can imagine, wrapping a tourniquet around a thigh and squeezing hard enough that no blood reaches the rest of the leg can cause some unwanted side effects. Tourniquets have been shown to cause temporary muscle and nerve damage at the areas where it is placed. In addition, the lack of oxygen to the rest of the leg can create injuries to the rest of the leg that then results in an inflammation cascade.
More inflammation means more pain.
The injuries to the muscle and nerves turn out to be temporary. The muscle and nerves do recover, but the temporary injury causes patients to recover more slowly.
Another potential issue with using a tourniquet is the formation of blood clots in the leg. One of the risks of knee replacement is blood clots that can then travel to the lungs and cause problems. Tourniquets have also been shown to increase the chances of a blood clot after surgery.
Why did I choose to stop using tourniquets?
I stopped using tourniquet with knee replacement surgies because it helps my patients recover quicker and have less pain.
Multiple studies show us that patients who have a “tourniquet free total knee,” or a knee replacement without a tourniquet, get better faster than those who don’t. They take less pain medicines. They are able to walk without an assistive device sooner. They are able to stand on one leg sooner. They get their range of motion back sooner.
Overall, they get better faster.
Since tourniquets do provide better visualization, can I still see what I am doing? The answer of course is yes. There are several key tools I use to minimize blood loss and improve visualization. For anesthesia, we use spinals and keep blood pressure at a safe but low level. We also us a drug called tranexamic acid which promotes clotting within the surgical field.
There has also been development of enabling technologies to help me control any blood loss. During the surgery I use a device called the Aquamantys which seals areas of bleeding. With these techniques, visualization is not an issue.
Tourniquet Free and Outpatient Total Joints
Performing tourniquet free total knees is one of the critical components of the Fast Track total joint program at Northside Hospital. Through this program we are able to send our patients home the same day as the surgery over 90% of the time.
In the long run there is no major difference between patients who have a knee replacement with or without a tourniquet. But in the short run, there is a huge difference in how quickly patients get back to the the things they want to do. For me, this is enough reason to make the switch.
I stopped using a tourniquet for total knees two years ago, and for my patients it has made a huge difference.
