ICJR REWIND: Reducing Tourniquet Use in TKA as a Pain Management Strategy
In an article originally published on April 8, 2018, researchers from NYU Langone Health ask the question: If we eliminate or reduce tourniquet use in our primary total knee arthroplasty patients, will we reduce postoperative pain and the need for opioids?
Orthopaedic surgeons have been identified one of the top prescribers of opioids.  So in the midst of a national conversation around the opioid epidemic in the US, it makes sense that innovative strategies to help reduce pain after joint replacement surgery – and, thus, reduce reliance on opioid pain-relieving medications – are being proposed.
One such strategy is multimodal pain management, which is already well ingrained in the management of joint replacement patients. And it’s working: A study presented at the 2017 meeting of the American Society of Anesthesiologists  showed that between 2006 and 2014, opioid use in patients recovering from hip and knee arthroplasty decreased by one-third. The authors attributed this to the adoption of multimodal pain management protocols.
What else can orthopaedic surgeons do to reduce opioid use in joint replacement patients? Is there some other way to decrease pain that would, in turn, decrease opioid use?
There just might be, according to Ran Schwarzkopf, MD, MSc, from NYU Langone Health. He and his colleagues are poised to examine the possibility of eliminating – or at least greatly reducing – the use of tourniquets in primary total knee arthroplasty procedures. The thinking is that postoperative thigh pain from tourniquet use may be contributing to the need for pain medication. Eliminating that source of pain could reduce the use of opioids.
First Step: Tourniquets and Blood Loss
As a first step, they conducted a meta-analysis and systematic review of tourniquet use in total knee arthroplasty to examine the role of the tourniquet in reducing blood loss and transfusions after primary procedures, as well as the role of tranexamic acid in accomplishing the same goal. If tranexamic acid is adequately controlling blood loss and reducing the need for transfusions, then there may be no advantage to continuing tourniquet use.
The study results were presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.
After a search of Pubmed, EMBASE, and the Cochrane Library using the keywords “tourniquet” and “total knee arthroplasty” and “tourniquet” and “total knee replacement,” Dr. Schwarzkopf and his colleagues identified 19 studies to include in the meta-analysis. These studies reported outcomes in 1094 primary knee arthroplasty patients. The data extracted from the studies were:
- Use of tranexamic acid
- Blood loss
- Incidence of venous thromboembolism (VTE)
- Wound complications
Although intraoperative blood loss was found to be significantly lower in patients who had a tourniquet than in patients without a tourniquet (P<0.01), differences in total blood loss and calculated blood loss were not significant. Wound complications were also significantly higher in tourniquet patients (OR 3.48; 95% CI 1.29-9.37; P=0.01). Tourniquet patients were more likely to develop VTEs, but this difference was not significant.
Subgroup analysis was also done to examine the impact of tranexamic acid. The researchers found total blood loss was significantly reduced in tourniquet patients who received tranexamic acid. When tranexamic acid was not used, tourniquet patients were at significantly greater risk of VTEs (OR 3.68 [0.86-15.76], P=0.08). The risk decreased when tranexamic acid was administered (OR 0.93 [0.08-10.4], P=0.95).
The researchers said the results of the meta-analysis suggest that tourniquet use should be reduced in primary total knee arthroplasty patients and tranexamic acid use should be encouraged, although they also noted that additional randomized controlled trials are needed to assess the clinical efficacy of this strategy.
“Since tranexamic acid has come into widespread use, transfusions in knee replacement and hip replacement have really decreased to the level that they’re almost non-existent in primary cases. So, there is no advantage for tourniquets or no tourniquets with regard to blood loss,” Dr. Schwarzkopf said.
Next Step: Tourniquets and Pain
The issue of postoperative pain following tourniquet use was not examined in any of the studies included in the meta-analysis; they focused on blood loss and transfusions.
Dr. Schwarzkopf and his colleagues are preparing to conduct a study evaluating thigh pain, opioid use, and outcomes with and without use of the tourniquet in primary total knee arthroplasty patients to determine if eliminating tourniquet use could be part of the “narcotic-sparing future” they envision.
“What we want to answer now is if the pain values are different and the narcotic use is different,” he said. “No one has actually done studies looking at tourniquet [use] and outcomes of opiate use and recovery. That’s what we’re looking at doing.”
Narayanan R, Anoushiravani A, Elbuluk AM, Chen K, Iorio R, Schwarzkopf R. Are Tourniquets Indicated in Total Knee Arthroplasty? A Meta-Analysis and Systematic Review (Paper 837). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.
The study authors have no disclosures relevant to this article.
- Morris BJ, Mir HR. The opioid epidemic: impact on orthopaedic surgery. J Am Acad Orthop Surg. 2015;23(5):267-71. doi: 10.5435/JAAOS-D-14-00163
- Gerner P, Poeran J, Cozowicz C, et al. Multimodal Pain Management in Total Hip and Knee Arthroplasty: Trends Over the Last 10 Years (abstract A1069). Presented at ANESTHESIOLOGY 2017, October 21-25, 2017, Boston, Massachusetts. A report on the study can be found here.