Total joint arthroplasty is commonly associated with post-operative anemia. Blood conservation programs have been developed to optimise patients prior to surgery. Epoetin Alfa (Eprex) or intravenous (IV) iron transfusions are two modalities that can be used pre-operatively to optimise hemoglobin and ferritin levels. There are, however, potential complications and increased costs associated with their use. Oral iron is a less costly option for those undergoing surgery but requires more time to take effect. There are no studies to date that examine the effects of an early screening program utilising oral iron supplementation prior to total joint arthroplasty. The purpose of this study is to evaluate the effect of implementing early pre-operative oral iron supplementation on patients prior total joint arthroplasty.

A retrospective review of patients undergoing total joint arthroplasty was performed using our institution clinical informatics database. We identified all patients seen in pre-admission clinic (PAC) between Jan 1, 2009 and March 31, 2010 representing our control group. We then identified all patients seen in PAC between October 1, 2012 and December 31, 2013. Patients in this cohort received screening blood work when booked for surgery, and oral iron supplementation was given to patients with hemoglobin of less than 135g/L or ferritin less than 100ug/L, thus representing our treatment group. Patients undergoing revision, uni-compartment knee arthroplasty and bilateral arthroplasties were excluded from the study. Pearson Chi-Square tests were used to calculate significance between groups with main outcomes including pre-admission hemoglobin, and pre-operative requirements for Eprex or IV iron.

In our control group, we identified 354 patients (25.6%) with hemoglobin less than 130 g/L at time of pre-admission clinic. In our treatment group, this number dropped significantly to only 16.4% of patients (p<0.005).

Implementation of an early screening program using oral iron supplementation resulted in a decrease in the number of patients with hemoglobin lower than 130 g/L at the time of pre-admission clinic. There was also a significant decrease in the use of Eprex and IV iron pre-operatively in the patients in the early screening program. These results encourage the use of early oral iron supplementation for patients with hemoglobin less than 135 g/L or ferritin less than 100ug/L in order to optimise patients prior to total joint arthroplasty.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected knee arthroplasty experts.

The primary cases will include challenges such as patient selection and setting expectations, exposure, alignment correction and balancing difficulties. In the revision knee arthroplasty scenarios issues such as bone stock loss, fixation challenges, instability and infection management will be discussed.

This will be an interactive case-based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

We present a case of multifocal infection involving the left total hip replacement and the right total knee replacement of a patient, further complicated by an infected non-union of a periprosthetic fracture of the right knee. This required the unique simultaneous management of both infection eradication and fracture stabilization in the knee.

Both sites were treated with a 2-stage procedure, including the novel use of a stemmed articulating spacer for the right knee. This spacer was made combining a retrograde humeral nail, coated with antibiotic-impregnated cement, and a pre-formed articulating cement spacer. The patient was able to weight-bear on this spacer. The fracture went on to unite, and a second stage was performed with the use of stemmed prosthesis and augments. She remains infection free 2 years after the second stage operation.

The use of a stemmed articulating knee spacer can facilitate infection eradication and fracture stabilization while preserving some motion and weight-bearing ability in the 2 stage management of an infected periprosthetic fracture of the knee.

Introduction

Total knee arthroplasty (TKA) has proven clinical success with reported longterm survivorship of 92% in the elderly population. Concerns regarding increased loosening rates and potential need for multiple revision surgeries in patients younger than 60 years have traditionally discouraged TKA in younger patients. The purpose of this study was to review the longterm clinical and radiographic results of patients under the age of 45 yrs who underwent a total knee replacement.

Objectives

Porous metal surfaces have been a popular option for acetabular component fixation in total hip arthroplasty (THA). New THA component designs are introduced periodically with the expectation of better wear properties and survivorship. Since its approval for use in 2002 there have been few clinical outcome studies published on the Pinnacle acetabular cup system. We hypothesised that the hemispherical porous coated Pinnacle acetabular cup system with a range of cup options and bearing surfaces would give us predictably good fixation and survivorship at five years post implantation.

Summary

The effect of polyethylene wear and lift-off between the tibial and femoral components on the mechanical axis was assessed in primary TKA (Total Knee Arthroplasty) based on retrieval data and full leg radiographs.

Introduction

Coronal plane alignment is one of the contributing factors to polyethylene wear in total knee arthroplasty (TKA). The goal of this study was to evaluate the wear and damage patterns of retrieved tibial polyethylene inserts in relationship to the overall mechanical alignment and to the position of the tibial component.

Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty.

Highly crosslinked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly crosslinked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. This replicates well the hip simulator data. The challenge, however, is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while 10-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally, while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly cross-linked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly crosslinked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode.

The question still remains as to the best material for the femoral ball. Essentially two options exist – cobalt chrome and ceramic (Delta). There are theoretically advantages to ceramic heads; however they come at a cost premium: 1.) To date there have been no published reports that demonstrate any improved clinical outcomes with the use of ceramic heads. In fact, the Australian registry demonstrates that the cumulative revision rate is lowest with CoCr heads (at 10 years, 4.3% with CoCr on XLPE and 4.6% with ceramic on XLPE). 2.) Costs continue to be significantly higher for ceramic heads. A price premium of 2–4× higher cost for ceramic over CoCr heads exists in most global markets. 3.) Trunion issues. An emerging concern is corrosion at the head neck junction in THA. Ceramic heads should theoretically have a lower incidence of taper corrosion. To date this is unproven, as is the actual incidence of this as a significant clinical problem.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected hip arthroplasty experts. The primary cases will include challenges such as hip dysplasia, altered bony anatomy and fixation challenges. In the revision hip arthroplasty scenarios issues such as bone stock loss, leg length discrepancy, instability and infection will be discussed. This will be an interactive case based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

Obesity is clearly a worldwide epidemic with significant social, health care and economic implications.

A clear association between obesity and the need for both hip and knee replacement surgery has been demonstrated. Specifically the presence of class 3 obesity (BMI > 40) increases the incidence of THA by 8.5 times and the incidence of TKA by 32.7 times, compared with patients of normal weight.

Issues related to TJA in the morbidly obese include:

Outcomes - There is a growing body of evidence to support the premise that patients undergoing either THA or TKA who are morbidly obese derive significant benefit from the surgical intervention. Specifically patient and disease specific outcome measures (WOMAC, SF-12, KSCRS, HSS) demonstrate equal change between pre-operative and post-operative scores in those patients of normal weight compared to the morbidly obese cohort.

There is little debate that performing total joint arthroplasty in the morbidly obese is technically challenging and that the potential for increased peri-operative morbidity, particularly in the form of infection is present. That being said, the realised benefit to the patient of the surgical intervention is significant, and denying surgery on the basis of obesity alone is not justified.

Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty.

Highly cross-linked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly cross-linked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. This replicates well the hip simulator data. The challenge, however, is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly cross-linked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly cross-linked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode.

The question still remains as to the best material for the femoral ball. Essentially two options exist – cobalt chrome (CoCr) and ceramic. There are theoretically advantages to ceramic heads; however, they come at a cost premium:

To date there have been no published reports that demonstrate any improved clinical outcomes with the use of ceramic heads. In fact, the Australian registry demonstrates that the cumulative revision rate is lowest with CoCr heads (at 10 years, 4.3% with CoCr on XLPE and 4.6% with ceramic on XLPE).

Costs continue to be significantly higher for ceramic heads. A price premium of 2–4x higher cost for ceramic over CoCr heads exists in most global markets.

Trunnion issues. An emerging concern is corrosion at the head neck junction in THA. Ceramic heads should theoretically have a lower incidence of taper corrosion. To date this is unproven, as is the actual incidence of this as a significant clinical problem.

Obesity is clearly a worldwide epidemic with significant social, healthcare and economic implications.

A clear association between obesity and the need for both hip and knee replacement surgery has been demonstrated. Specifically the presence of class 3 obesity (BMI > 40) increases the incidence of THA by 8.5 times, and the incidence of TKA by 32.7 times, compared with patients of normal weight.

Issues related to TJA in the morbidly obese include: Outcomes - There is a growing body of evidence to support the premise that patients undergoing either THA or TKA who are morbidly obese derive significant benefit from the surgical intervention. Specifically patient and disease specific outcome measures (WOMAC, SF-12, KSCRS, HSS) demonstrate equal change between preoperative and postoperative scores in those patients of normal weight compared to the morbidly obese cohort; Complications - It would appear that the rate of deep infection is increased in the morbidly obese, and that the greater the BMI, the greater the risk of infection. This is important to understand and appreciate preoperatively as the surgeon discusses the risk/benefit ratio of the operative intervention.

There is little debate that performing total joint arthroplasty in the morbidly obese is technically challenging and that the potential for increased perioperative morbidity, particularly in the form of infection is present. That being said, the realised benefit to the patient of the surgical intervention is significant, and denying surgery on the basis of obesity alone is not justified.

While no one would argue the necessary role for the medical management of patients with early knee arthritis, significant controversy remains regarding the ideal treatment for a patient with bone-on-bone osteoarthritis who could equally be treated with a high tibial osteotomy, a uni-compartmental total knee, potentially a patello-femoral replacement if dealing with isolated patello-femoral disease or lastly, a complete total knee replacement. While clearly to date there has not been consensus on this issue, a review of the arguments, both pro and con, should be used as a guide to the surgeon in making this clinical judgment.

Patient Satisfaction - Many ardent supporters of uni-compartmental knee replacements espouse one of the principle benefits of the uni knee as much greater patient satisfaction. Unfortunately, what is never taken into account is the pre-selection bias that occurs in this patient population. Patients with the most minimal amount of arthritis and those with the greatest range of motion are pre-selected to undergo a uni-compartmental knee replacement compared to the more advanced arthritic knee with malalignment and more significant preoperative disability that will undergo a total knee replacement. Additionally the sources of data to draw the conclusions must be carefully analyzed. We must avoid using data from small series with unblinded patients performed by surgeons expert in the technique. Instead registry data, with its broad based applicability, is a much more logical source of information. Of significance, when over 27,000 patients were assessed regarding satisfaction following knee surgery; there was no difference in proportions of satisfied patients whether they had a total knee or a uni-compartmental knee.

Implant Longevity - Once again large prospective cohort data in the form of arthroplasty registries strongly favors total knee arthroplasty over uni-compartmental knee arthroplasty. The Swedish Knee Arthroplasty Registry demonstrated higher revision rates with uni's as compared with total knee replacements. In the Australian Joint Replacement Registry the cumulative 13-year percent revision rate for primary total knee replacements is 6.8% and for uni-compartmental knee replacements is 15.5%. Higher failure rates in uni-compartmental knee replacements seen in Australia has correlated to a significant decrease in the number of uni's being performed, which peaked at 15.1% in 2003 and in 2014 has reduced to 4.7%. There is a direct correlation to age, with younger patients having a significantly higher percentage of revision following uni-compartmental knee replacements (25% failure rate at 11 years if less than 55 years old). There is also tremendous variability in the success rate of the uni in the Australian Registry depending on the implant design (5-year cumulative revision rate range 5.0% to 18.9%), which is simply not seen in the total knee replacement population (5-year cumulative revision rate range 1.6% to 7.7%).

While one can perform the philosophical exercise of debating the merits of a total knee versus uni-compartmental knee, the evidence is overwhelming that in the hands of the masses a total knee replacement patient will have equal satisfaction to a uni-compartmental patient, and will enjoy a much lower probability of revision in the short term and in the long term.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected hip arthroplasty experts. The primary cases will include challenges such as hip dysplasia, altered bony anatomy and fixation challenges. In the revision hip arthroplasty scenarios issues such as bone stock loss, leg length discrepancy, instability and infection will be discussed. This will be an interactive case based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

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.

Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty.

Highly crosslinked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly crosslinked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. The challenge, however, is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly crosslinked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly crosslinked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode.

During this same decade metal-on-metal implants had seen a significant resurgence in use. Metal-on-metal implants had in-vitro advantages with very low wear rates. They allowed the use of large metal heads and articulations, thereby improving range of motion and stability. Concerns always existed regarding the production of metal ions and the potential for metal hypersensitivity, as well as possible systemic effects. Metal hypersensitivity remains a diagnosis of exclusion with no definitive diagnostic tests to either screen for it, or diagnose it, if suspected. Over the past few years metal-on-metal implant use has dropped significantly, to the point now in 2013, where the only remaining application is resurfacing implants in the younger male patient.

Ceramic-on-ceramic bearings enjoy the lowest wear rates of all currently available hip articulations. Historically there has been concern regarding fracturing of both the inserts and the heads, although current generation ceramic-on-ceramic bearings have a much lower reported fracture rate. The phenomenon of a squeaking articulation remains a concern for both patient and surgeon. Conflicting reports exist on whether this is related to implant malposition or is a function of the bearing itself. As with other bearings, improvements in technology continue to evolve and newer ceramics have recently been introduced and are in clinical practice.

The future will continue to see the evolution of the articulation in total hip arthroplasty. Patients are undergoing total hip replacements at younger ages and clearly have higher demands than seen historically. That being said, two factors will have a major influence on future developments. The tremendous clinical success of highly crosslinked polyethylene should have us all question the need for significant changes in bearing material and the current environment following the multiple issues with metal-on-metal is one of evolutionary, rather than revolutionary, design and introduction.

Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty.

Highly cross-linked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly cross-linked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. This replicates well the hip simulator data. The challenge however is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly cross-linked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly cross-linked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode.

During this same decade metal-on-metal implants had seen a significant resurgence in use. Most major orthopaedic companies produced a metal-on-metal implant whether in the form of a more conventional modular insert, or a monoblock resurfacing-type implant, or both. Metal-on-metal implants had in-vitro advantages with very low wear rates. They allowed the use of large metal heads and articulations, thereby improving range of motion and stability. Concerns always existed regarding the production of metal ions and the potential for metal hypersensitivity, as well as possible systemic effects. Metal hypersensitivity remains a diagnosis of exclusion with no definitive diagnostic tests to either screen for it, or diagnose it, if suspected. Over the past few years metal-on-metal implant use has dropped significantly, to the point now in 2013, where the only remaining application is resurfacing implants in the younger male patient.

Ceramic-on-ceramic bearings enjoy the lowest wear rates of all currently available hip articulations. Historically there has been concern regarding fracturing of both the inserts and the heads, although current generation ceramic-on-ceramic bearings have a much lower reported fracture rate. The phenomenon of a squeaking articulation remains a concern for both patient and surgeon. Conflicting reports exist on whether this is related to implant mal-position or is a function of the bearing itself. As with other bearings, improvements in technology continue to evolve and newer ceramics have recently been introduced and are in clinical practice.

The future will continue to see the evolution of the articulation in total hip arthroplasty. Patients are undergoing total hip replacements at younger ages and clearly have higher demands than seen historically. That being said, two factors have will have a major influence on future developments. The tremendous clinical success of highly cross-linked polyethylene should have us all question the need for significant changes in bearing material and the current environment following the multiple issues with metal-on-metal is one of evolutionary, rather than revolutionary, design and introduction.

While no one would argue the necessary role for the medical management of patients with early knee arthritis, significant controversy remains regarding the ideal treatment for a patient with bone-on-bone osteoarthritis who could equally be treated with a high tibial osteotomy, a unicompartmental total knee, potentially a patello-femoral replacement if dealing with isolated patello-femoral disease or lastly, a complete total knee replacement. While clearly to date there has not been consensus on this issue, a review of the arguments, both pro and con, should be used as a guide to the surgeon in making this clinical judgment.

Many ardent supporters of unicompartmental knee replacements espouse one of the principle benefits of the uni knee as much greater patient satisfaction. Unfortunately, what is never taken into account is the pre-selection bias that occurs in this patient population. Patients with the most minimal amount of arthritis and those with the greatest range of motion are pre-selected to undergo a unicompartmental knee replacement compared to the more advanced arthritic knee with mal-alignment and more significant pre-operative disability that will undergo a total knee replacement. Additionally the sources of data to draw the conclusions must be carefully analysed. We must avoid using data from small series with unblinded patients performed by surgeons expert in the technique. Instead registry data, with its broad based applicability, is a much more logical source of information. Of significance, when over 27,000 patients were assessed regarding satisfaction following knee surgery; there was no difference in proportions of satisfied patients whether they had a total knee or a unicompartmental knee.

Once again large prospective cohort data in the form of arthroplasty registries strongly favors total knee arthroplasty over unicompartmental knee arthroplasty. The Swedish Knee Arthroplasty Registry demonstrated higher revision rates with uni's as compared with total knee replacements. In the Australian Joint Replacement Registry the cumulative 11 year percent revision rate for primary total knee replacements is 6.1% and for unicompartmental knee replacements is 16.3%. The 10 year cumulative percent revision rate for patella femoral replacements 29.9% and lastly bicompartmental replacements are at 10.3% after only 3 years. Higher failure rates in unicompartmental knee replacements seen in Australia has correlated to a significant decrease in the number of uni's being performed, which peaked at 14.6% in 2003 and in 2012 has reduced to 9.0%. There is a direct correlation to age, with younger patients having a significantly higher percentage of revision following unicompartmental knee replacements (25% failure rate at 11 years if less than 55 years old). There is also tremendous variability in the success rate of the uni in the Australian Registry depending on the implant design (5 year cumulative revision rate range 5.0% to 18.9%), which is simply not seen in the total knee replacement population (5 year cumulative revision rate range 1.6% to 7.7%).

While one can perform the philosophical exercise of debating the merits of a total knee versus unicompartmental knee, the evidence is overwhelming that in the hands of the masses a total knee replacement patient will have equal satisfaction to a unicompartmental patient, and will enjoy a much lower probability of revision in the short term and in the long term.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected hip arthroplasty experts. The primary cases will include challenges such as hip dysplasia, altered bony anatomy and fixation challenges. In the revision hip arthroplasty scenarios issues such as bone stock loss, leg length discrepancy, instability and infection will be discussed. This will be an interactive case based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

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.

There can be little debate that intraoperative 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 (intraop + postop) 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.

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.