Paul Sousa, Mahmoud Hafez, Matt Austin.

Response/Recommendation: There is inadequate evidence to link the use of lower extremity tourniquet during orthopedics procedures and postoperative venous thromboembolism (VTE).

Strength of Recommendation: Limited.

Rationale: The systematic review conducted identified a few studies related to the use of tourniquet and VTE or embolization.  Historical reports examined emboli using echocardiograms immediately following the release of a lower limb tourniquet^1–3.  In one particular prospective comparative study of 24 patients undergoing total knee arthroplasty (TKA), there was a 5.33 fold increase in large venous emboli with the use of a pneumatic tourniquet¹.  There is anecdotal evidence of patient mortality caused by exsanguination of a limb and inflation of a pneumatic tourniquet^2,3.

More recently, higher-level evidence has failed to demonstrate a significant relationship between tourniquet use and VTE^4–7.  The three prospective randomized studies evaluating tourniquet use in TKA, all failed to show a significant difference in symptomatic VTE^5–7.  Moreover, systematic review and meta-analysis of foot and ankle procedures demonstrated limited evidence for increased risk of VTE with the use of a tourniquet⁸.

Despite limited overall evidence for use of a tourniquet as a risk factor for VTE, tourniquet duration has been associated with VTE.  Two retrospective and one prospective study have examined this topic^9–11.  A registry study of 577 primary TKA patients demonstrated an increased risk of complications, including deep venous thrombosis (DVT) with tourniquet time over 100 minutes⁹.  It is worth noting that the relationship between tourniquet time and operative time is difficult to separate.  One retrospective comparative study of a single surgeon who routinely used a tourniquet and another who did not demonstrate a significantly higher rate of VTE with the use of a tourniquet.  However, a major confounding variable was surgical time, 72 vs. 36 min.  A systematic review of many studies on the topic over the last ten years shows a strong relationship between longer operative time and the risk of postoperative VTE¹².

To further complicate matters, there are other factors that have impeded definitive research on the topic.  For one, modern DVT prophylaxis and early ambulation has greatly reduced the incidence of symptomatic VTE¹³.  Although variably reported, one large series showed an incidence of VTE following primary TKA to be less than 0.31%¹⁴.  Moreover, the timing of tourniquet use is widely variable between surgeons.  Some surgeons have advocated the use of a tourniquet during cementation for TKA while others may use a tourniquet for the entire duration of the procedure.  A prospective randomized controlled study of half course vs full course tourniquet with 64 patients demonstrated no difference in symptomatic or asymptomatic VTE between groups¹⁵.  High-quality randomized data with adequate power is needed to further characterize the relationship between tourniquet use and VTE, but this may prove impractical.  One contemporary study hypothesized that a total of 3,400 patients would be needed to provide 95% power and 5% significance, assuming a baseline symptomatic VTE event rate of 1% and a minimally clinically important difference of 1%¹³.

References:

1.         Parmet JL, Horrow JC, Berman AT, Miller F, Pharo G, Collins L. The incidence of large venous emboli during total knee arthroplasty without pneumatic tourniquet use. Anesth Analg. 1998;87(2):439-444. doi:10.1097/00000539-199808000-00039

2.         Pollard BJ, Lovelock HA, Jones RM. Fatal pulmonary embolism secondary to limb exsanguination. Anesthesiology. 1983;58(4):373-374. doi:10.1097/00000542-198304000-00013

3.         Boogaerts JG. Fatal pulmonary embolism during limb exanguination. Can J Anaesth. 1998;45(10):1031-1032. doi:10.1007/BF03012315

4.         Fukuda A, Hasegawa M, Kato K, Shi D, Sudo A, Uchida A. Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg. 2007;127(8):671-675. doi:10.1007/s00402-006-0244-0

5.         Kim TK, Bamne AB, Sim JA, Park JH, Na YG. Is lower tourniquet pressure during total knee arthroplasty effective? A prospective randomized controlled trial. BMC Musculoskelet Disord. 2019;20(1):275. doi:10.1186/s12891-019-2636-7

6.         Park J-Y, Kim SE, Lee MC, Han H-S. Elastic pneumatic tourniquet cuff can reduce postoperative thigh pain after total knee arthroplasty: a prospective randomized trial. BMC Musculoskelet Disord. 2020;21(1):565. doi:10.1186/s12891-020-03579-6

7.         Liu P-L, Li D-Q, Zhang Y-K, et al. Effects of Unilateral Tourniquet Used in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty. Orthop Surg. 2017;9(2):180-185. doi:10.1111/os.12329

8.         Smith TO, Hing CB. The efficacy of the tourniquet in foot and ankle surgery? A systematic review and meta-analysis. Foot Ankle Surg. 2010;16(1):3-8. doi:10.1016/j.fas.2009.03.006

9.         Olivecrona C, Lapidus LJ, Benson L, Blomfeldt R. Tourniquet time affects postoperative complications after knee arthroplasty. Int Orthop. 2013;37(5):827-832. doi:10.1007/s00264-013-1826-4

10.       Rathod P, Deshmukh A, Robinson J, Greiz M, Ranawat A, Rodriguez J. Does Tourniquet Time in Primary Total Knee Arthroplasty Influence Clinical Recovery? J Knee Surg. 2015;28(4):335-342. doi:10.1055/s-0034-1388654

11.       Sullivan M, Eusebio ID, Haigh K, Panti JP, Omari A, Hang JR. Prevalence of Deep Vein Thrombosis in Low-Risk Patients After Elective Foot and Ankle Surgery. Foot Ankle Int. 2019;40(3):330-335. doi:10.1177/1071100718807889

12.       Zhang Z, Shen B, Yang J, Zhou Z, Kang P, Pei F. Risk factors for venous thromboembolism of total hip arthroplasty and total knee arthroplasty: a systematic review of evidences in ten years. BMC Musculoskelet Disord. 2015;16:24. doi:10.1186/s12891-015-0470-0

13.       Wilson DGG, Poole WEC, Chauhan SK, Rogers BA. Systematic review of aspirin for thromboprophylaxis in modern elective total hip and knee arthroplasty. Bone Joint J. 2016;98-B(8):1056-1061. doi:10.1302/0301-620X.98B8.36957

14.       Faour M, Piuzzi NS, Brigati DP, et al. Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prophylaxis Following Total Knee Arthroplasty. J Arthroplasty. 2018;33(7S):S131-S135. doi:10.1016/j.arth.2018.03.001

15.       Chen S, Li J, Peng H, Zhou J, Fang H, Zheng H. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. Int Orthop. 2014;38(2):355-359. doi:10.1007/s00264-013-2177-x