The study by Tetro and Rudan does not support the use of
a tourniquet in cemented total knee arthroplasty. When the tourniquet
and non-tourniquet groups were compared, there was no difference
in blood loss or transfusion requirements between them. Operating times
did not differ, and the senior surgeon believed that the bone surfaces were
adequate in both groups. The authors suggest that the risks associated with
tourniquet use (embolic events, venous thrombosis, altered wound-healing,
vascular compromise, increased swelling, and neurologic and muscular
damage) outweigh the benefits of tourniquet use (reduced blood loss,
improved surgical visualization, a potentially shorter operative
time, and cleaner, drier bone surfaces) in cemented total knee arthroplasty.
The authors raise an interesting question that will stimulate
debate. However, before their conclusions can be accepted, several
issues need to be considered. First, suction wound drains were used
for all total knee arthroplasties in this study. Previous research
has suggested that wound drains are not necessary in total knee
arthroplasty and may actually increase total blood loss after the
procedure1. Second, two-thirds
of the knees in this study had a lateral patellofemoral retinacular
release, which is associated with increased blood loss. Third, all
of the patients in the tourniquet group had the tourniquet released
intraoperatively to achieve hemostasis. Release of the tourniquet
after wound closure can minimize blood loss2.
Perhaps blood loss could have been reduced with use of a tourniquet
if the authors had minimized the use of lateral releases, closed
the wound with the tourniquet inflated, and eliminated suction drains.
The ultimate question to be answered, which was not addressed by this
study, is whether cement fixation and prosthesis survival are compromised
when a tourniquet is not used. Until this question is answered,
we believe that tourniquet use should be considered the rule rather
than the exception in cemented total knee arthroplasty, unless the
patient has a specific contraindication such as peripheral vascular
disease, severe peripheral neuropathy, or ipsilateral limb infection.