Abstract
The use of a tourniquet when performing total knee arthroplasty (TKA) is subject to different methodologies. Some surgeons see no need to use a tourniquet, others use the tourniquet only during cementation, some utilise the tourniquet from prior to incision to after cementation, while others maintain throughout and release after closure. At our center, use of the tourniquet is part of the TKA routine: position the patient, administer antibiotics, inflate the tourniquet, note pressure and time, complete preparation and draping, set time-out, and cut. We release the tourniquet after cementation of components, prior to assessment of patellofemoral tracking and closure. Advantages of using a tourniquet are enhanced TKA durability, less blood during cementation, and reduced intra-operative blood loss and need for transfusion. Adequately preparing the bone surfaces and cleaning away blood and fat are essential to good cement technique, providing better interdigitation and penetration and resulting in fewer radiolucencies and longer survivorship. Lateral retinacular release, performed to alleviate patellar maltracking, is not a benign procedure and is associated with increased patellar complications including loosening, fracture, and avascular necrosis. Several articles, including one from our center, have studied the effect of tourniquet deflation and patellar tracking, observing 31% to 86% reduction in maltracking and indication for lateral release when assessing after deflation. A prospective study of 28 patients undergoing same day bilateral TKA using a tourniquet inflated prior to incision and released after cementation on one side and either no tourniquet or tourniquet only during cementation of the contralateral side found slightly lowered quadriceps strength in the tourniquet group that persisted for up to 3 months. However, another recent prospective study of 120 patients assessing wound closure in 90 degrees flexion versus full extension, with the combination of an inflated versus deflated tourniquet, found that closure of the knee in flexion after tourniquet deflation significantly decreased post-operative pain and promoted early recovery of ROM. Safe use of the tourniquet is essential to avoid neurologic injury, and includes pneumatic, wider, contoured cuffs, moderate maximum applied pressure, and monitoring during release for emboli and metabolite return. Operative efficiency minimises overall operative and tourniquet time, thereby reducing risk of complications. Several meta-analysis reviews have compared TKA performed with versus without use of a tourniquet. All found using a tourniquet resulted in a significant decrease in operative time and intra-operative blood loss, but a trend for increase in deep vein thrombosis and wound complications. Other meta-analysis articles have studied time of tourniquet release comparing early versus late. These studies unanimously found late release to be associated with substantial increase in post-operative complications. Some studies found early release before wound closure to be associated with increased total blood loss and greater drop in hemoglobin while the other studies reported no differences in these measures. Our practice is to deflate the tourniquet prior to wound closure and to achieve hemostatis. The use of a tourniquet to perform TKA facilitates efficient operative technique, improves visualization of anatomical structures, facilitates the surgeon's focus on proper component positioning, and facilitates good cement technique.
