TOURNIQUETS

There were multiple studies evaluating pain and tourniquet use with six high quality studies (Ozkunt 2018, Liu 2017, Yi 2021, Hamawanadi 2021, Liu 2014, Ledin 2012) showing increased pain in the immediate postoperative period. Additionally, there is moderate evidence to support avoidance of using a tourniquet in order to decrease opioid consumption (Hamawanadi 2021, Kheir 2018, Nicolaiciuc 2019).

Studies regarding outcomes were heterogenous and inconclusive. Two high quality studies (Ozkunt 2018, Hamawanadi 2021) did not favor using a tourniquet and two high quality studies (Ayik 2019, Liu 2017) showed no significant difference for KSS. Four high quality studies showed no significant difference in motion, including total ROM (Ayik 2019, Liu 2017), flexion (Goel 2019, Alexandersson 2019), or extension (Alexandersson 2019).

Five high quality studies (Ledin 2012, Harsten 2015, Mori 2016, Goel 2019, Hamawanadi 2021) were in favor of using a tourniquet to reduce blood loss. However, there were different methods of blood loss calculation, and two studies (Ledin 2012, Mori 2016) did not use tranexamic acid (TXA). Three high quality studies (Goel 2019, Liu 2017, Hamawanadi 2021) showed no difference for deep vein thrombosis, moderate evidence (Alexandersson 2019, Yi 2021, Hamawanadi 2021) showed no difference for length of stay, and there were not enough high quality studies to show a difference for quadricep strength, wound complications, or operating time.

*KSS = Knee Society Score, ROM = range of motion

Benefits/ Harms of Implementation

Surgeons should take care to balance the advantages and disadvantages of using a tourniquet. Reported advantages of using a tourniquet include dry field, shorter operative time, better visibility, reduced blood loss, dry bone surfaces for better cement interdigitation and implant survivorship. Adverse effects include ischemia, quadricep muscle damage, increased swelling and stiffness, nerve compression, injury to calcified vessels, and potential for deep venous thrombosis (DVT). If a tourniquet is used, it is recommended to keep the surgical time down to decrease the risk for DVT.

Outcome Importance

The outcomes for TKA with tourniquet versus no tourniquet were equivalent. While there are limited studies in young patient populations, this recommendation may be used with caution in surgeon practices with younger patient populations as the use of tourniquet may cause increased quadricep pain and weakness.

Cost Effectiveness / Resource Utilization

This recommendation likely does not affect cost-effectiveness or resource utilization for a majority of surgeons. However, surgeons who desire to improve their efficiency may consider using it to decrease operating room time.

Acceptability

Surgeons will likely find the cumulative study results and recommendation acceptable.

Feasibility

There are a number of studies showing comparable outcomes with or without tourniquet use. It would be feasible for surgeons to consider the patient’s history when making a decision about using a tourniquet. Specific considerations would include a history of DVT, lower extremity vascular stents, and poor bone quality if cementing implants.

Future Research

There is a gap in the literature regarding the long term effect of tourniquet use and quadricep strength in younger patients. As the operative age continues to decrease and activity and expectations after total knee arthroplasty continue to increase, future studies should focus on this group of patients.