Changing the Order of Dressing Application and Tourniquet Release Can Reduce Blistering

    A study from The Rothman Institute showed a statistically significant reduction in blistering when the tourniquet was released before the compression dressing was applied in patients undergoing total knee arthroplasty.

    The incidence of skin blisters after total knee arthroplasty (TKA) doesn’t receive a lot of attention, but maybe it should: Blistering occurs in up to 20% of TKA patients. And it can lead to infection.

    The good news is that research from The Rothman Institute in Philadelphia has shown that preventing this blistering can be fairly simple: Release the tourniquet before – not after – applying the compression dressing.

    The research was presented at the recent 2015 ISAKOS Biennial Congress in Lyon France. Senior author William J. Hozack, MD, spoke with ICJR about the implications of the study. His comments can be found here.

    As Dr. Hozack and his colleagues noted, surgeons normally apply a compression dressing before releasing the tourniquet. But because limb volume increases about 10% after tourniquet release, the skin is subject to shearing forces between the skin layers and dressing. That can cause blistering.

    To determine if applying the compression dressing after tourniquet release would reduce blistering, the Rothman researchers conducted a prospective study that included 135 consecutive primary TKAs on 111 patients. Instead of applying the compression dressing before tourniquet release, they released the tourniquet immediately after wound closure, allowed complete reperfusion, and then applied the compression dressing.

    The study cohort was followed for 30 days and then compared with outcomes in historical controls (200 consecutive primary TKAs in 187 patients) in which the usual protocol of compression dressing followed by tourniquet release was used.

    Dr. Hozack performed all procedures in both groups using the same surgical technique. There were no differences in dressings used and perioperative care provided between groups. Tourniquet time and blood loss were similar between groups, as were patient demographics (age, gender, ethnicity, and body mass index).

    The researchers found a statistically significant reduction (P=0.028) in blistering between groups: The incidence of blistering in the control group was 7.5% (15/200), compared with 2.2% (3/135) in the study group.

    These results, the researchers concluded, indicate that, “releasing the tourniquet prior to dressing application reduces the incidence of blistering after TKA.”


    Heller S, Chen AF, Albert E, Hozack WJ. How to Reduce Blistering After Total Knee Arthroplasty: Release the Tourniquet Before Dressing Application (ePoster 1413). Presented at the 2015 ISAKOS Biennial Congress, June 7-11, 2015, in Lyon, France.