Abstract
There has been ongoing debate for many years on the relative merits of routine tourniquet use while performing a total knee replacement. Interestingly there have been many retrospective reviews and opinion articles on the topic, but little in the way of well powered prospective randomised clinical trials.
Those that dislike the premise of routine tourniquet use usually cite a list of either very rare complications, or theoretical concerns (nerve damage, muscle function, wound healing issues).
Like most debate topics, however, the issue is usually a shade of grey, rather than black and white, if the pro/con arguments are evaluated individually.
1. Blood Loss
There can be little debate that intra-operative blood loss is less with the use of a tourniquet. This has been demonstrated in multiple studies and is clearly intuitively obvious. Interestingly the overall blood loss (intra-op + post-op) may, however, be the same regardless of tourniquet use. Having a dry operative field, however, is important in achieving adequate cement fixation, and if tourniquet use is not employed, an alternative should be.
2. OR time
There is an overwhelming body of literature that supports the understanding that increased OR time directly correlates to increased infection rates in total joint arthroplasty. Proponents of not using a tourniquet will often have alternates to achieving a dry operative field that clearly add time to the procedure – meticulous hemostasis, air delivery systems, etc. This increased OR time may come at the cost of increased infection risk.
There is clearly a need for well-designed randomised clinical trials evaluating the practice of routine tourniquet use in TKA. Any trial done, however, must look critically at factors such as OR time, costs of alternatives, and potential long-term outcome effects.
