Anesthetic, Patient, and Surgical Risk Factors for Neurologic Complications After Prolonged Total Tourniquet Time During Total Knee Arthroplasty

Abstract

Nerve injury after prolonged tourniquet inflation results from the combined effects of ischemia and mechanical trauma. Tourniquet release, allowing a reperfusion interval of 10-30 min followed by re-inflation, has been recommended to extend the duration of total tourniquet time. However, this practice has not been confirmed clinically. We retrospectively reviewed the medical records of 1001 patients undergoing 1166 primary or revision knee replacements with tourniquet time more than 120 min during a 5-yr interval. Mean total tourniquet time was 145 +/- 25 min (range, 120-308 min). In 759 patients, the tourniquet inflation was uninterrupted. Two tourniquet inflations, interrupted by a single deflation, were noted in 371 patients, and 3 tourniquet inflations interrupted by 2 deflation intervals were noted in 23 patients. A total of 129 neurologic complications (peroneal and/or tibial nerve palsies) were noted in 90 patients for an overall incidence of 7.7%. Eighty-five cases involved the peroneal nerve and 44 cases involved the tibial nerve. In 39 cases, both peroneal and tibial deficits were noted. Complete neurologic recovery occurred in 76 (89%) peroneal and 44 (100%) tibial palsies. Postoperative neurologic dysfunction was associated with younger age (P < 0.001; odds ratio = 0.7 per 10-yr increase), longer tourniquet time (P < 0.001; odds ratio = 2.8 per 30-min increase), and preoperative flexion contracture >20 degrees (P = 0.002; odds ratio = 3.9). In a subset of 116 patients with tourniquet times > or =180 min, longer duration of deflation was associated with a decreased frequency of neurologic complications (P = 0.048). We conclude that the likelihood of neurologic dysfunction increases with total tourniquet time and that a reperfusion interval only modestly decreases the risk of nerve injury.

Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

“…Advantages of tourniquet use include improved visualization, reduced intraoperative blood loss, and enhancement of cement fixation [11,14,17,21,22,27,45,54]. Reported adverse effects of tourniquet use include reduced early knee flexion [11,14,60,62,65], increased perioperative pain [11,14,27,56], postoperative limb swelling [11,21,47], wound complications [9,12,40,41], and creation of cardiac and cerebral microemboli [16,20,[42][43][44]55]. Additionally, some have reported an increased incidence of deep venous thrombosis [8,57,65], arterial thrombosis in subjects with preoperative vascular disease [26,48,49], and peripheral nerve injury [28,39].…”

“…Application of a tourniquet during TKA has been frequently used to improve visualization of the operative field, decrease intraoperative blood loss [11,14,17,22,27,60,65], and improve the quality of cementation by providing a relatively bloodless operative field [21]. A 2010 analysis of current practice patterns of members of the American Association of Hip and Knee Surgeons found 95% of patients without vascular disease who underwent TKA had their procedures performed under tourniquet control [7].…”

Tourniquet Use During Cementation Only During Total Knee Arthroplasty: A Randomized Trial

“…The tourniquet was released in all patients at the completion of cementation of the patella and the knee held in extension with compression of the patella for the subsequent 10 minutes it took for cement to complete polymerization. Exclusion criteria were diabetes, rheumatoid arthritis, calcified vessels on radiograph, history of thromboembolism, active cancer, and angular deformity in any plane beyond 10°(20°flexion contracture increases neurological complications [8,17]). These exclusions are accepted as high risk in previous randomized studies [1,25,26,28].…”

“…Several randomized controlled trials of tourniquet versus no tourniquet use during this operation have shown no statistical difference or even less total blood loss when no tourniquet is used [1,2,10,12,14,15,[25][26][27][28][29] . Moreover, there are potential complications associated with tourniquet use: nerve palsy [8,19], delayed recovery of muscle power from microscopic changes in muscle myofibrils [21], wound complications [1,12,25], and venous thrombotic embolism [1,10,12]. Deflation of the tourniquet can cause respiratory and cardiac complications in patients with poor cardiac function [7,18].…”

Peripheral nerve injuries

“…Nerve injury related to tourniquets results from two pathological processes: mechanical compression and neural ischemia. Horlocker et al [9] found there to be a three-fold increase in risk of nerve damage for every 30 min increase in tourniquet inflation time. Tourniquet related nerve injury is widely documented in the literature, [10] however, permanent femoral nerve injury secondary to tourniquet use is sparsely reported.…”