I discontinued tourniquet for knee replacement to reduce blood loss

Why I stopped using a tourniquet for total knee replacement

1/27/2018

,It has been customary for decades to use a pneumatic tourniquet during total knee replacement surgery. Inflation of the tourniquet initiated the very first total knee replacement I saw as a medical student, every total knee replacement I did during training, and nearly every total knee I performed while in practice.

The perceived benefit of tourniquet use was reduced blood loss and better visualization of the tissues during surgery.

Total blood loss is defined as any blood loss during surgery, PLUS any postoperative blood loss into dressings or drains, or into the joint or leg. This can be quantified by comparing pre-operative hematocrit (blood count) with the lowest post-operative hematocrit.

A recent paper suggests that total blood loss paradoxically INCREASES if a tourniquet is used during surgery. A variety of additional recent papers suggest the same thing. How can this be?

Reactive Hyperemia (a period of increased blood flow after tourniquet release)

While a tourniquet is inflated, arterial inflow to the limb is stopped. This is nice for the surgeon during the operation as visualization is easier, and no time needs to be spent controlling bleeding. Many surgeons release the tourniquet at the conclusion of the operation, but prior to closing the incision. This allows any bleeding to be controlled. This was what I always did, because I wanted to be sure all active bleeding was stopped prior to wound closure. I hoped to minimize any post-operative bleeding as well as total tourniquet time. Some surgeons do not choose to do this but maintain the tourniquet until a compressive dressing has been applied.

The problem is that after the period of ischemia (no blood flow), the tissues demand more blood supply, and the blood flow to the limb increases for a period of time after surgery. This is known as reactive hyperemia. As a result, sometimes after surgery, blood will collect in the knee, accumulate in the dressing, and/or be removed in a drain. This can be uncomfortable for patients and it increases total blood loss.

There are other downsides of tourniquet use. Intravenous antibiotics are given just prior to initiation of surgery to help reduce the chance of infection. While this medication is infused prior to tourniquet inflation, once the tourniquet is inflated, blood is no longer circulating and thus, antibiotic medication is not circulating either. Ischemic tissues will become cold making cellular activity and enzymes less effective. Ischemia is stressful to the tissues. This increases inflammation. The tourniquet applies significant pressure to the soft tissues. This can contribute to pain and bruising of the thigh postoperatively. Because the tourniquet stops blood flow, it also increases the chance of blood clot formation.

I encountered occasional cases where the tourniquet didn't work well. This can happen if a patient has high blood pressure, their arteries are calcified, or if their thigh is large. In these cases the tourniquet restricts venous outflow but allows arterial inflow since arterial pressure is higher. We refer to this as a "venous tourniquet." When this happened I would drop the tourniquet and carry on as usual. The operation went fine. A bit more time was needed to stop bleeding during surgery, but the results were no different than when using a tourniquet.

Based on this, the theoretical negative tourniquet effects, and the recent papers suggesting tourniquet paradoxically increases total blood loss, I decided to stop inflating the tourniquet for total knee replacements.

I spend a few more minutes controlling bleeding during the surgical approach. Once this initial bleeding is controlled, there is minimal ongoing blood loss for the remainder of the case. This is analogous to total hip replacement where tourniquet use is impossible due to the location of surgery.

Visualization is excellent. The bone ends are irrigated using pulsatile lavage, and dried as usual prior to implanting the knee replacement components. By this stage of the operation, the knee looks basically the same as it does when using a tourniquet. Prior to closure, all bleeding has stopped. No drain is necessary. Tranexamic acid is a medication that helps reduce blood loss, and we use this in most patients.

I have been very pleased with the results since I have discontinued routine use of the tourniquet for total knee replacement surgery. I found patients are more comfortable and there is noticeably less swelling and bruising. Knee range of motion has been returning quicker.

We are continually working on process improvement to allow patients to return to their normal life as rapidly as possible. This begins with preoperative education, continues with a multimodality pain management plan, a 3-dimensionally planned, robotically assisted joint replacement operation, and early mobilization. My experience is that discontinuing use of the pneumatic tourniquet is yet another step to help patients recover quicker.

26 Comments

EIleen holdridge link

1/30/2018 05:47:26 pm

Read your comments on the best way to do knee replacement..the best way to control the bleeding & clotting..Also more comfort when u r able to use the knee when u are able to do so ..... good read..Thanks good info..EIleen Holdridge

Christopher Gorczynski, MD link

1/30/2018 06:00:43 pm

My goal is continuous improvement, working toward "perfect."Glad you enjoyed the post.

Dianne

10/3/2020 04:56:22 pm

The use of a tourniquet on my husband for TKR was a TN(Total Nightmare). Not only did the doctor use a tournequit but an ace bandage was put on afterwards that was too tight for too long. His entire hamstring was purple for weeks and he screamed in pain when it was moved or even touched. Knee rehabilitation was impossible until weeks later when it was too late and scar tissue developed causing a stiff knee resulting now in further procedures to get the knee to bend. I would NEVER recommend a tourniquet EVER!

10/8/2020 02:37:27 pm

I am sorry to hear about your husbands difficulty. To be clear, careful use of a tourniquet is not likely to result in the outcome you describe. Some bruising is normal and anticipated after surgery, with or without a tourniquet. While some thigh pain is thought to result from tourniquet use, patients often experience thigh pain even after tourniquet-less knee replacement. An overly tight dressing is definitely something to avoid.

I avoid a tourniquet based on my ability to perform the operation safely without it, and with the expectation of reduced overall blood loss. Avoiding ischemia and allowing antibiotic circulation throughout surgery are also advantages of a tourniquet-free total knee replacement.

The lesson here is that once surgery is done- no matter how unpleasant it feels, it is crucial to regain range of motion early. Throughout this website I describe why this is, and how I recommend stretching.

Patients often make the mistake of waiting for the knee to feel better before stretching adequately. It is extremely difficult to "catch up" once you have fallen behind on rehab.

Lori Stevens

3/13/2018 09:28:30 pm

Very interesting. I love how dynamic modern medicine is and how the negative effects of using a tourniquet have been recognized and eliminated. Certainly makes sense when you read all the side effects of the tourniquet use. Very glad you have decided not to use it routinely, just because that's what you were taught, or because that's what everyone else is doing. Thank you for teaching what you learned.

Mr David E Cooksey link

8/21/2018 09:45:39 am

Well what a delight to read. I'm an operating department practitioner in the UK on the anaesthetic side but have become part of a very interesting orthopaedic project and the use of the tourniquet for knee replacements has been aggressively discussed. The tourniquet has simply become a habitually routine device to use for knee replacements. However it is hugely debated that its benefits are generally only of benefit to the surgeon providing a clear bloodless surgical field and reduced blood loss (periop yes, post op no). However the potential complications are often not valued by the surgeon, but often managed by the anaesthetist, especially during reperfusion. I would suggest that patients are reliably educated with respect to the tourniquet and be provided the opportunity to accept or decline it's use for a total knee arthroplasty.

DAVE MCDONALD

2/19/2020 09:45:08 am

I've had a fem_pop and abt to have TKR and using a tourniquet would destroy the by_pass

2/19/2020 07:47:38 pm

I definitely would consider the history of femoral-popliteal bypass a very good reason to avoid using a tourniquet during surgery.

Ron Miller, MD

3/10/2020 11:09:17 pm

I just completed my first TKR 1 week ago. It was my second knee operation, the first being a 1974 ACL repair. With that for comparison, I was appalled and revolted to see the massive trauma wrought on my leg from hip to ankle. After some reading, I must believe that the massive bruising and terrible, unexpected swelling are from the tourniquet. The placement of the prostheses went well, I think, but even though I'm doing the prescribed PT, I believe it'll take 2-3 weeks for the swelling and bruising to resolve enough that the PT can be effective.
If I require a 2nd TKR, there will be NO intraoperative tourniquet. Parenthetically, my hgb dropped from 15.6 to 11.3, so it's hard to believe that the tourniquet reduced total blood loss.

3/11/2020 10:16:14 pm

Total knee replacement is definitely a bigger operation than ACL reconstruction. Some patients will experience significant swelling and bruising for a couple of weeks after surgery. This can happen with, or without the use of a tourniquet. There are definitely tradeoffs when a surgeon choses to use a tourniquet- while it makes the surgery a little quicker and easier, it can paradoxically increase total blood loss due to reactive hyperemia (increased blood flow after the tourniquet is released). My experience performing total knees without a tourniquet has been very good. Our overall blood loss is lower. It avoids ischemia (low tissue oxygen), keeps the operative limb warmer, allows antibiotic to circulate through the limb throughout the case, and patients appear less inflamed after surgery. I feel these benefits are worth the few extra minutes required of me to control bleeding as I go.

I would recommend using ice, and trying your best to stretch as much as possible- I have several articles you can reference on this website to help guide your exercises.

Best of luck!

Marla

9/23/2020 08:39:08 am

Just browsing the web. I haven’t even been to see an orthopedist yet but have joined a total knee replacement group on fb. I went to see my primary 3.5 years ago about my knee and she ended up sending me to a vascular surgeon and that ended up being 1.5 years of every other week doctor visits and procedures. Venous insufficiency from standing on my feet as a hairdresser for 30 years. My mom and I were talking and she recommended the doctor who did both of her replacements and I visited their website and watched a video about this doctor doing no tourniquet knee replacement. It intrigued me. In the fb group I’m in someone just mentioned the trauma to her leg from the tourniquet she had. That got me to thinking about my vascular issues and after reading your article I think I definitely need to use a doctor who does not use a tourniquet due to my prior vascular issues,
Thanks for the insightful article. I’m still standing several days out of the week in my profession and wear my compression hose every day. I’m self employed and need to be back in my feet as soon as possible. Just trying to do some research prior to. Thanks!

9/23/2020 08:24:21 pm

I definitely support your decision to seek out a surgeon that performs tourniquet-less knee replacement.

Here is another recent article supporting this technique:

https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-020-03623-5

Eddie

11/9/2020 09:07:06 am

I'm 4 days out from a TKR with accompanying tourniquet. I also had a partial on the other knee in August, also with a tourniquet. Some of my worst post-op pain came from the tourniquet site.

I don't know about your procedures, but my surgeries were called minimally invasive. The procedures used incisions about 6" long, slightly to the inside of the knee & slightly angled. As it was explained to me, the techniques optimally preserve soft tissue & leave the quads intact.

My doctor told me this surgery is more difficult than traditional methods & had a long learning curve. Do the differences with this technique necessitate a pristine bloodless field for success? I imagine the reduced damage to soft tissue could justify a tourniquet for surgical convenience even if the techniques could deal with a little blood.

I'm sure there are trade-offs & it's reasonable to expect a balance between time spent & patient benefit. For me, it's moot now; however, I was trained at work in continuous quality improvement. I'm a person who speaks up for the benefit of others.

Thanks for any insight you can offer.

11/26/2020 01:43:30 pm

This approach does not require a more pristine bloodless field. As you correctly state, there are definitely trade-offs with different approaches. The most important thing is appropriate implant positioning and soft tissue balance. The next most important thing is proper rehabilitation effort performed by the patient. Different approaches, tourniquet use, implant choice...these are all nuances and are less important than doing the operation well and rehabilitating optimally. Best of luck to you!

Dana link

12/24/2020 12:14:54 pm

Finally I found a site regarding TKR. I had my Rt knee replaced 1/2019 and almost 2 years later I still have pain, swelling and much disappointment because I tried above and beyond with therapy and acupuncture. My RT leg is straight bending motion amazing, still numb rt side of implant. Right after I was released from the hospital I noticed sharp groin pain that traveled upward on the leg (underwear line) then to the left side of the implant down the front of the leg...It comes and goes after I walk a bit. The inside pain still exists even during the night when I sleep. ? I'm 5'7" 160 lbs and was very athletic most of my life. .Dr. took x rays 1/2020 everything looks good, sent me home. Told me it takes time to heal. 12/23/2020 came back because the groin pain that travels up then to the knee etc. became worse, same, blood work looks great he said. What is a knee replacement when after a few minutes of walking the sharp groin pain freezes me in place. My Dr. did use a tourniquet and no I was no informed prior to surgery. I kept telling my Dr. I feel misaligned, he took X rays and said no I wasn't. I sure could use some help here because I still have my left leg to do. I used to be in tennis tournaments, dancing contests etc in my youth.

12/24/2020 10:28:19 pm

While I have stopped using a tourniquet for knee replacement surgery, it is not inappropriate for a surgeon to use one. Different surgeons have different comfort levels with this. Tourniquet use was the standard for decades.

I don't think that the tourniquet or your total knee replacement could be causing your groin pain. Particularly this far out from surgery. This is not a typical pain referral pattern. The numbness you report is totally normal and expected. Here is a blog posting explaining this:

https://www.yourorthomd.com/orthopedic-knowledge/numb-patch-on-knee-after-knee-replacement

Groin pain typically suggests a problem with your hip joint. Considering that you already have undergone knee replacement surgery, it is certainly possible that your hip is arthritic. In addition to groin pain, an arthritic hip often causes radiation of pain down the thigh and into the inside aspect of the knee.

If you have not done so already, i would suggest getting some hip x-rays.

Joseph A Marksz

2/3/2021 06:30:51 pm

I am currently researching for my near future TKR. After a bad experience with Blood Flow Restriction technique in physical therapy a while back, I'm really hoping to find a surgeon in the Denver or Tampa area that is quite comfortable with not using it. At least not for the entire procedure. Do you have any suggestions as to how to find such surgeons? I've read a few studies that seem to indicate it's overall benefits but not sure how common it is nowadays.

I hope to find a surgeon that employs both a muscle sparing and non-tourniquet technique. However, I do wonder whether there is too many challenges in employing both techniques together. Do I increase my risk of ending up with less then optimal alignment and/or cementing? Is it too hard to work through a smaller incision unless you stop blood flow? Is it harder to get the bone dry enough for excellent, long term cementing. I did read about a study that only used the tourniquet just before cementing and combined that with using some type of compressed gas to dry out the ends of the bone. I believe the tourniquet was on for only 10/15 minutes.

Thanks in Advance for Your Help...

2/4/2021 11:18:31 pm

If this is important to you, guess you should call just call around to local orthopedic offices and ask. As you correctly note- the most important thing about knee replacement is to get proper alignment and soft tissue balance. Then the patient needs to rehabilitate properly. Beyond these issues we are getting into nuance. While I think there are advantages to avoiding a tourniquet, there are clearly trade-offs. Surgery may take a few minutes longer, and may be a bit more tedious for the surgeon early on in the case while bleeding is controlled. I personally think the biological advantages to the patient are worth these irritations to me. The incision size is really irrelevant to getting a good result. I would caution that trying to achieve the smallest incision possible does increase risk of suboptimal alignment, cementation, etc. It may also cause some unnecessary skin trauma due to stretching. I personally do not feel using a tiny skin incision provides much value to the patient and does add some small amount of risk. It is not generally difficult to get a dry bone surface without a tourniquet since when cementing, the knee is placed in a position of hyperflexion, and the tibia is delivered anteriorly. This positioning usually restricts blood flow to the cut tibial surface quite well for those few minutes. Studies have investigated cement penetration with and without tourniquet with mixed findings. I am not aware of anything definitive with regard to longevity of implants. Perhaps consider a modern non-cemented knee prosthesis. Since cement is not used, it makes this issue completely immaterial.

8/7/2021 07:24:11 am

I wrote to you about a year ago about my husband who had severe tourniquet damage. The knee is stiff with not much range of motion. He is considering getting a revision and this new surgeon wants to use a tourniquet. I feel this would be a HUGE mistake as my husband now has vericose veins and venus insufficiency leakage and swelling and is having procedures to help with the leakage. I feel if another turniquet is used it could only cause worse damage because his veins are already bad an he now has high blood pressure. I need to find a doctor that will not use this barbaric procedure. We are in South Jersey. I can’t go through the nightmare I went through with him again. He won’t listen to me and I know I am right about this. I feel he could lose the use of his leg entirely if he allows this procedure again. His body can not handle it. He needs a doctor that cares about HIM and not just the money. Any advise would be so helpful. Thank you so much, Dianne

8/19/2021 04:30:21 pm

While I certainly understand your concerns, the use of a tourniquet has been standard practice for decades, and is certainly not considered inappropriate. I explained some potential advantages of tourniquet avoidance in the article above, but I do not mean to suggest that it should never be used. There is no financial advantage for your surgeon to use a tourniquet. If this issue is a deal-breaker for you, consider getting a second opinion.

Jane Cox link

10/12/2021 10:38:28 pm

I have a question. Is it beneficial for PT to use cups on a TKR 4 months post-op and 1 week after MUA?

10/17/2021 06:53:14 am

This is not a routine modality in my practice. If you recently underwent a manipulation under anesthesia, it means you had inadequate range of motion for this stage of recovery. My advice is to do long duration stretches as I instruct throughout this website. While I doubt it will cause harm, cupping will not help improve your knee range of motion. My recommendation is simple- just stretch and use ice.

Diane

1/24/2022 03:18:38 am

I am 7 week post op from a right total knee replacement. A tourniquet was used and I suffered extreme swelling and bruising which urged my surgeon to tell me to go to an ER after hours in fear of a blood clot. It was found I was fine, no blood clot(s). However, while I know a numb patch on the outside of my knee is normal- my entire inner thigh from groin to the inside of my knee is completely numb even now at 7 weeks post op. And in this area I am often experiencing what feels like a shooting, stabbing and burning sensations. Sometimes it can be as sharp and sudden as an electric shock that comes out of nowhere. I feel like this might be a complication from tourniquet use and when I ask my surgeon about it he doesn't ever really address it. I almost feel like he's avoiding the subject. And I don't think he believes me or is taking me seriously in the amount of pain it is causing me. All of this has caused very slow progress in PT but at least here at 7 weeks I am finally at 117 degrees. My big question is- if I were to seek a second opinion/investigation of this inner thigh/knee numbness and internal stinging/burning/stabbing....what doctor should I seek? A neurologist?

2/26/2022 03:36:52 pm

If this remains a problem for you, I would recommend evaluation by a neurologist. Perhaps an EMG/nerve conduction test would be appropriate. I am glad to hear you have not let this issue impede your rehabilitation.

Ray D.

7/4/2023 03:35:31 am

I had a left TKR on May 1, 2023. I am now 9 weeks out from surgery. I was prescribed TED stocking for 6 weeks. I am still wearing a thigh high TED stocking on my surgical leg to this day. When I remove the stocking, my knee and the upper outside portion of my calf immediately swell and fill with blood. My skin turns and almost deep purple - like bruising. The swelling impairs my mobility. I have alerted my surgeon to this numerous times and have sent photos of my knee in this state. He said it’s reactive hyperemia, which is normal. Should I still be experiencing hyperemia this far out from surgery?!?

11/4/2023 05:16:05 pm

Reactive hyperemia is usually a fairly brief increase in blood flow following a period of blood flow restriction. It sounds like you are experiencing fairly normal inflammation following surgery. This will likely persist to some extent for several months following surgery. Expect warmth, swelling, and a feeling of tightness. These all should gradually improve as the healing process progresses.

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Why I stopped using a tourniquet for total knee replacement

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