Charles P. Hannon, Nicolaas C. Budhiparama, Matthew P. Abdel.
Response/Recommendation: Lower extremity tourniquets may be associated with an increased risk of venous thromboembolism (VTE) post-operatively and should be used with caution in patients at a high risk of VTE.
Strength of Recommendation: Moderate.
Rationale: Tourniquets are commonly used during total knee arthroplasty (TKA) to minimize blood loss and to improve visualization during surgery1. However, there is still controversy regarding the impact of tourniquets on postoperative pain, functional outcomes and complication rates after surgery1–6. Specifically, there are concerns that tourniquet use may be associated with an increased risk of VTE post-operatively1–3.
Several meta-analyses investigating the association between tourniquet use and the incidence of VTE postoperatively have yielded mixed results1–3,7–10. Xie et al., in a meta-analysis of 14 randomized controlled trials reported that tourniquet use doubled the risk of postoperative VTE compared to no tourniquet use2. Similarly, Migliorini et al., in their meta-analysis including both randomized and non-randomized studies found that tourniquet use increased the risk of postoperative VTE four-fold, but this increase was of borderline statistical significance10. Two meta-analyses also reported an increased risk of postoperative VTE with use of a tourniquet1,7.
In contrast, several meta-analyses have reported no difference in VTE rates between patients who had tourniquet use and no tourniquet use during TKA8,9. Cai et al., included 541 TKA from 11 randomized controlled trials and found no difference in VTE rates between patients who had tourniquets and those that did not8. However, one limitation of meta-analyses published to date is that the majority of these included a single study with a high rate of postoperative deep venous thrombosis (DVT) that was inconsistent with other studies. In a study of 103 patients who were not given chemoprophylaxis post-operatively and were screened for asymptomatic VTE, Mori et al., observed that 53% of patients with a tourniquet (n=27) had a VTE post-operatively compared to 23% of patients without a tourniquet (n=12)11. Including this study in a meta-analysis artificially inflates the rate of VTE, as most surgeons in contemporary practice provide chemoprophylaxis post-operatively and do not perform routine VTE screening in asymptomatic patients. A recent systematic review by Ahmed et al., excluded this study in a meta-analysis of 17 randomized controlled trials3, noting an increased risk of VTE with the use of tourniquet compared to no tourniquet use, although this only approached statistical significance (relative risk [RR] 1.95, 95% confidence interval [CI] 0.99 to 3.82).
An additional limitation of the literature is the heterogeneity in the way tourniquets are used, which may influence the rate of VTE post-operatively. Some surgeons use a tourniquet from incision to closure, others use it for cementation only, and the remainder use a tourniquet until the cement is dry and let it down prior to wound closure. Zhang et al., investigated the timing of tourniquet release and its impact on post-operative pain and complications in a meta-analysis of 11 randomized controlled trials1. In their series of 670 TKAs, they found that early release of the tourniquet before wound closure was associated with fewer VTE post-operatively compared to late release after wound closure1. In addition to variation in the duration of tourniquet use, there is also variation in the cuff pressure selected among different surgeons. Consequently, it is unknown how different cuff pressures influence the rate of post-operative VTE.
With varied data on the influence of tourniquet use on the incidence of VTE post-operatively, it is recommended that surgeons use tourniquets with caution in patients who are at high risk of VTE or ischemia-related events post-operatively. Examples include patients with evidence of calcification of their popliteal or distal superficial femoral artery on radiographs, low ankle-brachial index, history of VTE, peripheral vascular or arterial disease, or absent or asymmetrical pedal pulses. In these patients, avoidance of a tourniquet should be considered. However, if a tourniquet is used, minimizing the duration of tourniquet use and the cuff pressure could help to minimize complications postoperatively.
1. Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2014;9(1):13. doi:10.1186/1749-799X-9-13
2. Xie J, Yu H, Wang F, Jing J, Li J. A comparison of thrombosis in total knee arthroplasty with and without a tourniquet: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2021;16(1):408. doi:10.1186/s13018-021-02366-w
3. Ahmed I, Chawla A, Underwood M, et al. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. Bone Joint J. 2021;103-B(5):830-839. doi:10.1302/0301-620X.103B.BJJ-2020-1926.R1
4. Goel R, Rondon AJ, Sydnor K, et al. Tourniquet Use Does Not Affect Functional Outcomes or Pain After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial. J Bone Joint Surg Am. 2019;101(20):1821-1828. doi:10.2106/JBJS.19.00146
5. Rantasalo M, Palanne R, Vakkuri A, Olkkola KT, Madanat R, Skants N. Use of a Tourniquet and Spinal Anesthesia Increases Satisfactory Outcomes After Total Knee Arthroplasty: A Randomized Study. J Bone Joint Surg Am. Published online June 15, 2021. doi:10.2106/JBJS.20.02080
6. Weber KL, Jevsevar DS, McGrory BJ. AAOS Clinical Practice Guideline: Surgical Management of Osteoarthritis of the Knee: Evidence-based Guideline. J Am Acad Orthop Surg. 2016;24(8):e94-96. doi:10.5435/JAAOS-D-16-00160
7. Liu Y, Si H, Zeng Y, Li M, Xie H, Shen B. More pain and slower functional recovery when a tourniquet is used during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2020;28(6):1842-1860. doi:10.1007/s00167-019-05617-w
8. Cai DF, Fan QH, Zhong HH, Peng S, Song H. The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: a meta-analysis. J Orthop Surg Res. 2019;14(1):348. doi:10.1186/s13018-019-1422-4
9. Yi S, Tan J, Chen C, Chen H, Huang W. The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2014;134(10):1469-1476. doi:10.1007/s00402-014-2056-y
10. Migliorini F, Maffulli N, Eschweiler J, Knobe M, Tingart M, Betsch M. Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism. Surgeon. Published online May 6, 2021:S1479-666X(21)00069-X. doi:10.1016/j.surge.2021.03.004
11. Mori N, Kimura S, Onodera T, Iwasaki N, Nakagawa I, Masuda T. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: A prospective, randomized study. Knee. 2016;23(5):887-889. doi:10.1016/j.knee.2016.02.007