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The Trouble with Tourniquets

The widespread application of tourniquets during routine joint surgery is a troubling topic that has implications for the rates of post-operative arthrofibrosis. But questioning traditional surgical methods can be sensitive. If you’re an orthopaedic surgeon who uses tourniquets please read this blog knowing that it has been written with the best interests of those needing joint surgery at heart, and that could be any of us. I hope that you, and others, find the information below useful.


The highest rates of post-operative arthrofibrosis are from total knee replacement and anterior cruciate ligament reconstruction, in which tourniquets are routinely applied.

One issue with tourniquets is that hypoxia (lack of oxygen) is among the most powerful drivers of fibrosis known [1] and tourniquets create hypoxia by reducing blood flow. For this reason a growing number of arthrofibrosis surgeons avoid tourniquets during lysis of adhesion surgery (release of scar tissue). But what about other knee surgeries? The highest rates of post-operative arthrofibrosis are from total knee replacement (TKR) and anterior cruciate ligament reconstruction (ACLR) [1], in which tourniquets are routinely applied. It occurred to me that it’s not possible to apply tourniquets during total hip replacement surgery or shoulder surgery, yet these operations are safe and effective. So, I was interested to follow the scientific evidence supporting tourniquet use during routine surgical procedures (non-emergencies). I was surprised to read that despite their widespread application it’s been known for a long time that tourniquets are harmful, as explained below, and their use is at best controversial [2].


ACL reconstruction surgery without the use of a tourniquet
ACL reconstruction surgery without the use of a tourniquet.

So why use a tourniquet? Tourniquets create a blood-free zone that should allow faster operating times. Some have argued that the use of tourniquets is necessary to provide better visibility, reduce blood loss [2] and permits stronger cementing of the prosthesis to bone. The majority of earlier studies investigating the use of tourniquets were “of very low-evidence quality” [3, 4] with a high risk of biased reporting and contradictory results. However, these beliefs have now been properly tested and found to be lacking in support (see specific references below). A significant amount of tourniquet-induced harm is caused by the restricted blood flow which prevents nutrients and oxygen reaching cells below the site of application. This is referred to as ischemia and hypoxia, respectively.


However, as we’ll explore, the harm from tourniquets is far greater than ischemia and hypoxia alone. Recent quality reviews comparing tourniquet use with no tourniquets during TKR surgery are clear - there are fewer post-operative complications when tourniquets are avoided and post-operative recovery of knee function is faster [3]. Tourniquet use is associated with more post-operative pain and swelling, less range of motion, delayed rehabilitation, muscle atrophy, peripheral nerve injury [5], wound complications, venous thrombosis (DVT) and increased risk of infection [2, 3, 6].


Tourniquet use is associated with more post-operative pain and swelling, less range of motion, delayed rehabilitation, muscle atrophy, peripheral nerve injury, wound complications, venous thrombosis and increased risk of infection

A high quality study by Zhao et.al. [2] found that “entirely avoiding a tourniquet in TKA reduces total blood loss and hidden blood loss when multiple doses of intravenous tranexamic acid are used. It is also associated with less pain, less lower limb swelling, less inflammation and muscle damage, and faster recovery.” In addition, the authors report that avoiding a tourniquet improved range of motion in the early postoperative period, an important consideration for arthrofibrosis risk. The absence of a tourniquet was associated with longer operating time, but not with impaired visibility. Zhao et.al’s study was high quality, had a very low risk of bias with randomisation, blinding (concealment of patient allocation) of surgeons, nurses, patients and assessors, appropriate control groups and a comprehensive panel of tests. The authors found that by limiting the time of tourniquet application to around 20 minutes, compared to the typical application of over an hour, reduced inflammation and muscle damage but these damaging effects were still greater than when tourniquet use was avoided completely (see graphs below)."


Figure from Zhao et. al. 20202: Mean pre- and postoperative levels of A: the inflammatory biomarker interleukin-6 (IL-6) and B: muscle damage (creatine kinase). *Significant differences (p < 0.05) among the three groups, measured by one-way analysis of variance. Pre = preoperative; POD = postoperative days.
Figure from Zhao et. al. 20202: Mean pre- and postoperative levels of A: the inflammatory biomarker interleukin-6 (IL-6) and B: muscle damage (creatine kinase). *Significant differences (p < 0.05) among the three groups, measured by one-way analysis of variance. Pre = preoperative; POD = postoperative days.

I approached Austrian orthopaedic surgeon Prof. Ralf Rosenberger for comment and he confirmed that “I do not use tourniquets in routine TKA or arthroscopic interventions. We routinely use intravenous tranexamic acid and epinephrine injected in the capsule and ligaments for vessel constriction/less bleeding. We have done this since 2012 when we started the Rapid Recovery Program. We see less bleeding, less pain and less swelling postoperatively. In most cases we avoid using Redon drainage.” When I asked him to describe the downsides of avoiding a tourniquet during at TKR has said “There are no cons… a tourniquet is definitely not necessary in routine TKR”.


It was difficult to find a high quality study into tourniquet use for ACLR surgery. A study by Choudhary et.al [6]. has weaknesses, but their randomised, blinded and controlled study of 45 patients is at low risk of bias. They concluded that “tourniquet use is associated with increased pain and analgesic requirement in early postoperative period which affects early rehabilitation of patients and these [effects] could be minimized by avoiding tourniquet inflation and using other methods to create bloodless field during ACL reconstruction”. A marker of muscle damage (CPK) was measured at post-operative day 1 and found to be significantly higher in the tourniquet group, and these patients experienced difficulties performing straight leg raises in the early post-operative period.


The trouble with tourniquets: There are a number of aspects to the harm done by tourniquets, which are known to alter normal physiology [7]. While a tourniquet is inflated ischemia and hypoxia generate oxidative and metabolic stress and cells begin to produce excessive amounts of damaging reactive oxygen species [7, 8]. There is progressive hypoxia, increasing acidity and cooling in the affected limb [5, 7]. At the same time, compression of tissues under a tourniquet can cause crush injuries to blood vessels, nerves and muscles [5, 8]. But this is only half the story, and there is worse to come.


Ischemia/reperfusion injury: Blood circulation is restored after the release of a tourniquet and a large influx of toxic compounds from cell death and damage, reactive oxygen species and inflammation from the isolated limb flood the bloodstream and tissues, causing secondary injury that is referred to as ischemia/reperfusion injury [9, 10]. This is a serious local and systemic (whole body) reaction that damages muscles, impairs kidney function and potentially injures vital organs [4, 7, 8]. The body reacts to damage by promoting a pro-inflammatory state [7], creating more damage, and so there is even more dysfunction and cell death, and more systemic and local inflammation. Ischemia/reperfusion reactions continue for an extended time post surgery [10], increasing secondary injuries [11]. One study showed that ischemia and muscle damage continued for at least 3 hours after tourniquet release [12].


Pain: Tourniquets increase the amount of pain experienced during surgery, as indicated by heart rate and increased blood pressure, and after surgery [8]. This is partly explained by the release of prostaglandins by injured cells. Prostaglandins are hormone-like molecules that have a range of functions including sensitising and exciting pain receptors [8]. Hence peripheral pain perception is increased and central pain sensitisation can also occur due to ischemia in the affected limb [8]. Tourniquets have been shown to increase the amounts of inflammatory cytokines [2], which signal to nerves and ramp up pain (see Why Pain Control is Important). In addition, nerves can be directly damaged (crushed) by the pressure applied by a tourniquet as well as by ischemia/hypoxia [5]. This can lead to temporary or permanent sensory abnormalities, pain, numbness and even paralysis [5, 8].


Bleeding and swelling: Major bleeding, mostly on the day of surgery, is quite common and is strongly associated with poor surgical outcomes [13]. Bleeding is another powerful promoter of fibrosis and arthrofibrosis [1], and reducing bleeding should be a surgical priority. Tourniquets interfere with normal coagulation (blood clotting), with increased clotting during initial tourniquet inflation and decreased clotting later, due to increased fibrinolytic activity (breaking down of blood clots) [7 , 8]. This leads to more post-operative bleeding [8]. In addition, small blood vessels are damaged by reperfusion effects and become leaky, with blood escaping into the soft tissues of the joint [14] and increasing the inflammatory response. This results in increasing tissue swelling [4, 5] and oedema that can cause “post-tourniquet syndrome”, characterised by swelling, stiffness and weakness that develops 1-6 weeks after surgery [5]. The increased swelling further increases blood vessel compression and tissue hypoxia [11, 14].


On another front, bleeding blood vessels can be missed during tourniquet use, and those that aren’t cauterised (to block them) can bleed for a prolonged period after wound closure [14], increasing total and post-operative blood loss [2, 3] and the risk of developing arthrofibrosis. Some authors suggest that avoiding a tourniquet may prompt surgeons to improve their surgical techniques and blood loss management [2], including cauterising bleeding blood vessels before closure.


Muscle atrophy (loss of muscle): The use of tourniquets is well known to be associated with increased muscle atrophy [5, 7] with reported decreases of mid-thigh quadriceps (thigh muscles) volume of 12 % at one week [7] and 20% at one month after surgery [2]. A marker of unregulated cell death, called pyroptosis, increases dramatically after 30 minutes of ischemia from compression in an animal model [9]. Pyroptosis of muscle cells is caused by inflammation [9] and contributes to muscle atrophy, a well-known side-effect of TKR surgery [7]. Immunohistochemical staining of muscle tissue demonstrates a significant amount of muscle damage, swelling and extensive muscle atrophy that increases with increasing duration of ischemia caused by compression [9]. The inflammation created by pyroptosis creates more inflammation, amplifying the inflammatory cascade and promoting additional chemokines, cytokines and adhesion molcules [9] that also cause fibrosis.


For some, muscle atrophy becomes permanent. However, even knees that have apparently healed well after TKR surgery in which a tourniquet was applied were found to have 20% less muscle mass in the quadriceps at one month post-op and lower quadriceps strength at three months [2].


Other methods to control bleeding: There are chemical options for reducing blood loss during and after surgery. Recent reviews of high quality studies concluded that tranexamic acid is a safe and effective choice for reducing the risk of surgical bleeding [13], including during TKRs. It significantly reduces blood loss and the need for blood transfusions [13], operative time, length of hospital stay as well as decreasing re-operations due to complications [15]. Zhao et.al. routinely incorporate multiple injections of tranexamic acid to reduce bleeding during and after TKR surgeries, finding that it’s effective and does not increase thrombotic events such as deep vein thrombosis [2]. This group found that multiple injections significantly reduce blood loss and are more effective than a single injection. Tranexamic acid reduces blood loss by increasing the stabilisation of blood clots (inhibiting the activation of plasminogen) [15].


The majority of reviews and studies I have read comparing tourniquet use to no tourniquet for TKR procedures make no mention tranexamic acid injections or other chemical means of reducing blood loss, so I assume they were not utilised. This is perhaps not surprising given that a recent audit found that at least a third of patients undergoing major surgery in the UK did not receive tranexamic acid despite it being a National Institute for Health and Care Excellence (NICE) quality standard since 2016 [13].


Cementing the prosthesis: But is there a need for a clean, bloodless area for strong bonding of the prosthesis cement? This question was addressed by Ledin et. al [16]. who randomised 50 TKR patients to either have a tourniquet, or not, with blinded assessments. Chemical control of bleeding was not mentioned. Range of motion was monitored for 2 years together with movement of the prosthesis, which was assessed with radiostereometric analysis (RSA). In RSA metal microbeads are embedded into the joint so the position of the implant can be precisely established using X-rays. The authors state “Our RSA data do not support the view that tourniquet use will improve fixation. We found no statistically significant effect on prosthesis migration”. As with other studies, they found that tourniquet use was associated with more pain and reduced ROM. It’s worth mentioning that one of the tourniquet patients (and none in the no-tourniquet group) required a manipulation under anaesthesia, after which their ROM was no longer measured or included in the results. ROM remained reduced after 2 years in the tourniquet patients compared to that in the no-tourniquet group.


ROM remained reduced after 2 years in the tourniquet patients compared to that in the no-tourniquet group.

So far as I know there haven’t been any studies into how tourniquet use affects the rates of arthrofibrosis. However, given the evidence of harm from tourniquet use, and lack of quality evidence supporting them, perhaps the time has come to replace tourniquets with tranexamic acid and other methods to control bleeding. The future in which tourniquets are avoided during all routine joint surgeries, including TKRs and ACLRs, should be now, and if you have surgery planned I believe it would be worth looking for a surgeon with this approach. Note that a tourniquet is always fitted on the limb prior to surgery but is not inflated unless there is a medical emergency. As a side note, I also believe that blood flow-restricted exercise should not be used during arthrofibrosis treatment, as it has real potential to promote arthrofibrosis for the same reasons.


Please remember that avoiding the use of a tourniquet during surgery is not a guarantee that arthrofibrosis won’t occur, since wounding stimulates arthrofibrosis. Even with the best care there are never any guarantees. However, I believe that minimising harm is important, and together with other arthrofibrosis-avoidant approaches (e.g. regular passive stretching, avoiding damaging exercise of the affected leg) avoiding tourniquets will increase the likelihood of a favourable outcome.


Feel free to use the IAA Surgical Checklist for further questions to ask your surgeon before surgery.


References
  1. Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research 7 (2019). https://doi.org/10.1038/s41413-019-0047-x

  2. Zhao, H. Y. et al. The effect of tourniquet uses on total blood loss, early function, and pain after primary total knee arthroplasty: a prospective, randomized controlled trial. Bone Joint Res 9, 322-332 (2020). https://doi.org/10.1302/2046-3758.96.BJR-2019-0180.R3

  3. Jiang, F. Z., Zhong, H. M., Hong, Y. C. & Zhao, G. F. Use of a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Sci 20, 110-123 (2015). https://doi.org/10.1007/s00776-014-0664-6

  4. Halladin, N. L., Zahle, F. V., Rosenberg, J. & Gogenur, I. Interventions to reduce tourniquet-related ischaemic damage in orthopaedic surgery: a qualitative systematic review of randomised trials. Anaesthesia 69, 1033-1050 (2014). https://doi.org/10.1111/anae.12664

  5. Masri, B. A., Eisen, A., Duncan, C. P. & McEwen, J. A. Tourniquet-induced nerve compression injuries are caused by high pressure levels and gradients - a review of the evidence to guide safe surgical, pre-hospital and blood flow restriction usage. BMC Biomed Eng 2, 7 (2020). https://doi.org/10.1186/s42490-020-00041-5

  6. Choudhary, A., Kanodia, N., Agrawal, S., Bhasin, V. B. & Singh, A. Tourniquet Use in Arthroscopic ACL Reconstruction: A Blinded Randomized Trial. Indian J Orthop 55, 384-391 (2021). https://doi.org/10.1007/s43465-020-00250-z

  7. Leurcharusmee, P., Sawaddiruk, P., Punjasawadwong, Y., Chattipakorn, N. & Chattipakorn, S. C. The Possible Pathophysiological Outcomes and Mechanisms of Tourniquet-Induced Ischemia-Reperfusion Injury during Total Knee Arthroplasty. Oxid Med Cell Longev 2018, 8087598 (2018). https://doi.org/10.1155/2018/8087598

  8. Kumar, K., Railton, C. & Tawfic, Q. Tourniquet application during anesthesia: "What we need to know?". J Anaesthesiol Clin Pharmacol 32, 424-430 (2016). https://doi.org/10.4103/0970-9185.168174

  9. Li, N. et al. Delayed step-by-step decompression with DSF alleviates skeletal muscle crush injury by inhibiting NLRP3/CASP-1/GSDMD pathway. Cell Death Discov 9, 280 (2023). https://doi.org/10.1038/s41420-023-01570-3

  10. Wu, M. Y. et al. Current Mechanistic Concepts in Ischemia and Reperfusion Injury. Cell Physiol Biochem 46, 1650-1667 (2018). https://doi.org/10.1159/000489241

  11. Zhou, T., Prather, E. R., Garrison, D. E. & Zuo, L. Interplay between ROS and Antioxidants during Ischemia-Reperfusion Injuries in Cardiac and Skeletal Muscle. Int J Mol Sci 19 (2018). https://doi.org/10.3390/ijms19020417

  12. Ejaz, A. et al. Tourniquet induced ischemia and changes in metabolism during TKA: a randomized study using microdialysis. BMC Musculoskelet Disord 16, 326 (2015). https://doi.org/10.1186/s12891-015-0784-y

  13. Grocott, M. P. W., Murphy, M., Roberts, I., Sayers, R. & Toh, C. H. Tranexamic acid for safer surgery: the time is now. Br J Surg 109, 1182-1183 (2022). https://doi.org/10.1093/bjs/znac252

  14. Wang, K. et al. The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 25, 2849-2857 (2017). https://doi.org/10.1007/s00167-015-3964-2

  15. Hong, P. et al. Does Tranexamic Acid Reduce the Blood Loss in Various Surgeries? An Umbrella Review of State-of-the-Art Meta-Analysis. Front Pharmacol 13, 887386 (2022). https://doi.org/10.3389/fphar.2022.887386

  16. Ledin, H., Aspenberg, P. & Good, L. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthop 83, 499-503 (2012). https://doi.org/10.3109/17453674.2012.727078


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